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Exit Interview Template -Form Fill
Identification and Background Information
Q01
Name of Interviewer
Q01A
code of Interviewer
Q02
Name of Supervisor
Q02A
code of Supervisor
Q03
Date of interview
Q04
State Code
Assam
Madhya Pradesh
Rajasthan
Q05
District Code
Q05A
Assam
Goalpara
Dibrugarh
Q05B
Madhya Pradesh
Chhatarpur
Shivpuri
Panna
Rewa
Tikamgarh
Raisen
Q05C
Rajasthan
Pali
Chittorgarh
Karauli
Banswara
Jaisalmer
Sikar
Q06
Block Code
Q07
Type of location
Urban
Rural
Q08
Village Name/town name
Q09
Type of facility
Primary Health Centre
PHC - Health and Wellness Centre
Sub-center
SC - Health and Wellness Centre
Q10
Facility Code
Q10_1
Facility 1
Q10_2
Facility 2
Q10_3
Facility 3
Q11
Full Name of the facility
Survey Information
A01
Date of Interview
A02
Interview Start Time
A03
Interview End Time
A04
Age in complete years
A05
Marital status
Single/unmarried
Married
Divorced
Widow
Separated
Destitute
A06
Did you avail/receive any family planning services from this facility?
Yes
No
A07
Is the woman eligible for exit interview?
Yes
No
A08
Result of the Interview
Interview started & completed
Interview Incomplete/ interrupted
Other (Specify)
A09
Do you consent to participate in the research?
Yes
No
Background Information
B01
What is your Educational Qualification?
Illiterate/no formal education
1st -5th class
6th -8th class
9th -10th class
11th -12th class
Graduate and above
B02
What is your religion?
Hindu
Muslim
Christian
Sikh
Buddhist
Jain
Parsi/Zoroastrian
No religion
Others (Specify)
Don’t know
B03
Do you belong to a scheduled caste, a scheduled tribe, other backward class, or none of these?
Scheduled Caste
Scheduled Tribe
Other Backward Class
General
None of the above
Don’t know
B04
Are you currently employed / self-employed?
Yes
No
B05
Apart from housework, what kinds of work did you do in the last 12 months?
Self‐employed in agriculture/ fishery/ orchard/ animal husbandry
Self‐employed in non‐agriculture
Regular salaried/wage employee in government/ private sector
Casual wage labour in public works (e.g., MGNREGA)
Casual labour in agriculture
Casual labour in non‐agriculture other than public works
Traditional service occupation (Cobbler, Dhobi, Barber)
Unpaid family workers in agriculture / fishery / orchard /animal husbandry
Unpaid family worker in non-agriculture
Domestic Worker /Cook
Unemployed
No work
Others (Specify)
B06
What is the Education Qualification of your husband?
Illiterate/no formal education
1st -5th class
6th -8th class
9th -10th class
11th -12th class
Graduate and above
B07
Is your husband currently Employed/ self-employed?
Yes
No
B08
Apart from housework, what kinds of work did your husband did in the last 12 months?
Self‐employed in agriculture/ fishery/ orchard/ animal husbandry
Self‐employed in non‐agriculture
Regular salaried/wage employee in government/ private sector
Casual wage labour in public works (e.g., MGNREGA)
Casual labour in agriculture
Casual labour in non‐agriculture other than public works
Traditional service occupation (Cobbler, Dhobi, Barber)
Unpaid family workers in agriculture / fishery / orchard /animal husbandry
Unpaid family worker in non-agriculture
Domestic Worker /Cook
Unemployed
No work
Others (Specify)
B09
What is the monthly consumption expenditure of household?
B10
What was your age, in completed years, at the time of your marriage?
B11
How long have you been married to your husband?
B12
Have you ever been pregnant in your entire life?
Yes
No
B13
How old were you when you got pregnant for the first time?
B14
What is the total number of living children you have at present?
Access and experience at facility
C01
I would like to ask for what Family planning service did you visit this Facility today?
Consultation for family planning methods / contraceptives
Counseling for family planning
To seek care for Side effects
To avail follow up care for FP method opted
For discontinuation/ removal of IUCD/Implant
Others (Specify)
C02
Which service provider did you meet there?
ANM
CHO
Staff nurse
Medical officer
Pharmacist
Family planning counsellor/ RMNCH-A
Others (specify)
C03
Is this the closest health facility (including any private facility) to your current residence?
Yes
No
C04
What were the reasons you did not go to the facility nearest to your home?
No family planning services available at the nearest center
Inconvenient operating hours
Bad reputation / bad prior experience
Don't like personnel /staff
No medicine /commodities available
Prefers to remain anonymous
It is more expensive than other options
Was referred/ suggested by ASHA
Less convenient location
Absence of provider
Other (Specify)
Don’t know
C05
Why did you choose this facility?
Good experience with previous visit
Good service quality
OPD timings are convenient
Affordable/low-cost contraceptive methods
Trust the provider/personnel
Availability of contraceptive methods
Availability of providers
Advised by friends/family
Suggested by ASHA
Close to home
Others (specify)
C06
Of those that you have just mentioned reasons , what was the main reason behind choosing this facility for the services you received today?
Good experience with previous visit
Good service quality
OPD timings are convenient
Affordable/low-cost contraceptive methods
Trust the provider/personnel
Availability of contraceptive methods
Availability of providers
Advised by friends/family
Suggested by ASHA
Close to home
Others (specify)
C07
Which sources of information influenced your decision to come to this facility today?
ASHA
ANM
AWW
LHV/other health worker
Pharmacist
Stree clinic
Local leader
Self Help Groups (SHGs)
FP helpline number
Husband
Friends/ Neighbour
Family Members/Relatives
Outdoors (Hoardings, Wall Painting, Kiosk, Directional Board & Banner)
Television
Newspaper/magazine
Radio
Mobile/Internet
Social media platforms
Others(specify)
C08
Of those that you have just mentioned, what was the most important source which influenced you for choosing this facility?
ASHA
ANM
AWW
LHV/other health worker
Pharmacist
Stree clinic
Local leader
Self Help Groups (SHGs)
FP helpline number
Husband
Friends/ Neighbour
Family Members/Relatives
Outdoors (Hoardings, Wall Painting, Kiosk, Directional Board & Banner)
Television
Newspaper/magazine
Radio
Mobile/Internet
Social media platforms
C09
How far is this facility from your home?
C10
How much time did it take you to travel here today?
C11
With whom did you visit this facility today?
Husband
Mother-in-law
Sister-in-law
Mother
Friends /relatives/ neighbor
ASHA
Self
Others (Specify)
C12
What mode of transport did you use while going to the facility/service provider?
Walking
Bicycle
Tractor
Motorcycle
Auto rickshaw/tempo
Taxi/Jeep/Van
Ambulance
Bus
Train
Other (specify)
C13
How long did you have to wait before you were first seen by a service provider?
< 15 minutes
15 – 30 minutes
30 – 60 minutes
60 – 90 minutes
90 – 120 minutes
>120 minutes
Family planning consultation and counselling services
D01
Before coming to the facility, which FP methods were you aware of?
28- days contraceptive pills
Weekly contraceptive pills
Emergency contraceptive pills
Condom or Nirodh
Female condom
Antara- IM / DMPA IM
Antara -SC/ DMPA SC
IUCD or PPIUCD
Implants
Female sterilization
Male sterilization
Standard days method
Lactational amenorrhoea method (LAM).
Rhythm method
Withdrawal
Folk methods
No method
Others (specify)
D02
What was the main purpose of your visit to this facility?
To get counselling to explore and start using family planning methods
Continue with or restart the method already using
Switch method
To get counselling to stop using method (due to problems)
Stop using method (elective-no problems)
D03
Before coming to the facility today, have you used a family planning method or taken any steps to prevent pregnancy at any time during the past 6 months?
Yes
No
D04
What method were you last using before visiting the facility?
28- days contraceptive pills
Weekly contraceptive pills
Emergency contraceptive pills
Condom or Nirodh
Female condom
Antara- IM / DMPA IM
Antara -SC/ DMPA SC
IUCD or PPIUCD
Implants
Female sterilization
Male sterilization
Standard days method
Lactational amenorrhoea method (LAM).
Rhythm method
Withdrawal
Folk methods
No method
Others (specify)
D05
Were you using some other methods along with Condom?
Oral Contraceptive Pills - 28 days pills
Oral Contraceptives - weekly pills
Emergency contraception
Injectables – DMPA -Intramuscular
Injectables – DMPA -Sub-cutaneous
IUCD or PPIUCD
Implants
Female sterilization
Male sterilization
Standard days method
Lactational amenorrhoea method (LAM)
Rhythm method
Withdrawal
No method
Others (specify)
D06
Have you been having (did you have) any problems with the contraceptive method?
Yes
No
D07
Did a provider ask you today whether you were having (or had) a problem with the method?
Yes
No
D08
Did you mention the problem to the provider during the consultation?
Yes
No
D09
Did the provider suggest any action(s) you should take to resolve the problem?
Yes
No
D10
What was the outcome of this visit—did you decide to continue (restart) the same method or to switch methods?
Start using family planning method
Continue with or restart the same method.
Switch method
Stop using method
D11
Why have you stopped using the method?
Difficulty in accessing the method
Discontinuation based on the healthcare provider's recommendation due to health concerns
Changes in a partner's preferences or concerns about the usage of contraceptive methods
Past experience of unpleasant or bothersome side effects
Fear of side effects on future fertility
Cultural or religious beliefs
Stigma and social pressure
Partner migrated and started living away
Elective (no problem)
Others (Specify)
D12
Why have you switched to a different contraceptive method than the one you were previously using?
The currently preferred method is more accessible
Partner has a preference for a different contraceptive method
Experienced uncomfortable side effects or discomfort
Desire for a More Effective Method
Received better education or information about contraceptive options
The previous contraceptive method failed to prevent pregnancy
Others (Specify)
D13
Had you thought about switching methods, and which method to switch to, before you came here today?
Yes
No
D14
Had you thought about what family planning method you wanted to use before you came here today?
Yes
No
D15
What method was that?
Oral contraceptive Pills
Emergency contraception
Condom or Nirodh
Female condom
Injectables:
IUCD or PPIUCD
Implants
Standard days method
Lactational amenorrhoea method (LAM)
Rhythm method
Withdrawal
Others (specify)
D16
Which type of oral contraceptive pills?
28-days oral contraceptive pills
Weekly oral contraceptive pills
Type unspecified
Others
D17
Which types of injectables?
Antara-IM /DMPA IM
Antara-SC/DMPA SC
Type unspecified
Others (Specify)
D18
What family planning methods did the provider talk with you about?
Oral contraceptive Pills
Emergency contraception
Condom or Nirodh
Female condom
Injectables:
IUCD or PPIUCD
Implants
Standard days method
Lactational amenorrhoea method (LAM)
Rhythm method
Withdrawal
Others (specify)
D19
Which oral contraceptive pill was discussed with you?
28-days oral contraceptive pills
Weekly oral contraceptive pills
Type unspecified
Others
D20
Which injectables were discussed with you?
Antara-IM /DMPA IM
Antara-SC/DMPA SC
Type unspecified
Others (Specify)
D21
Did you receive any referrals or prescriptions for any of the following methods?
D21A
Method
Oral contraceptive Pills
Emergency contraception
Condom or Nirodh
Female condom
Injectables
IUCD or PPIUCD
Implants
Female sterilization
Male sterilization
Lactational amenorrhoea method (LAM)
Others (specify)
Continuing with method
No method was prescribed/ referred
D21B
Prescription/Referral
Yes
No
D22
Which oral contraceptive pill was prescribed /given to you?
28-days oral contraceptive pills
Weekly oral contraceptive pills
Others
Don’t know
D23
Which injectable is prescribed/given to you?
Antara /DMPA IM
DMPA SC
Others (Specify)
D24
Which type of sterilization method was recommended to you/ your husband?
Minilap sterilization
Laparotomy
Conventional tubectomy
Conventional vasectomy
No-scalpel vasectomy
D25
Before prescribing any method, were following information gathered from you?
Age of the woman
Number of children
Age of the youngest child
Past Experience with family planning methods
Last method use
Cause of discontinuation
Previous use of same method
Experience of side-effects from the same method
Date of last menstrual period
Regularity of period
Bleeding/Spotting between periods or after intercourse
Details of deliveries and abortions
Details of post-partum/post abortion infections
Any complaint of abnormal vaginal discharge
Any medical illness
Other (specify)
D26
Before prescribing any method, were following examinations or/and lab tests advised/ done?
Pallor
Pulse rate
Blood Pressure
Body weight
Examination of abdomen
Respiratory rate
Body temperature
Pelvic examination
External genitalia examination
Speculum examination of the vagina and cervix
Auscultation of Heart and Lungs
Pregnancy test
Blood test
Urine test for sugar
Other blood tests
No examination/ lab test done
D27
Finally, today which method did you chose from the list of prescribed or referred methods?
Oral Contraceptive Pills - MALA-N
Oral Contraceptive Pills - CHHAYA
Emergency contraception
Condom or Nirodh
Female condom
Antara-IM /DMPA IM
Antara-SC/DMPA SC
IUCD or PPIUCD
Implants
Female sterilization
Male sterilization
LAM
Not yet decided
D28
Who made the final decision?
Respondent /Self alone
Spouse
Jointly with spouse
Mother-in-law
Other relatives
Provider
D29
During your visit today, did you recieve the method of family planning prescribed to you?
Yes
No
D30
Why have you not yet decided to choose any method from the prescribed list?
Fear of side-effects
Lack of trust in the service provider
Lack of trust in the facility
Accessibility issues
Requires a discussion with partner
Requires a discussion with family/ relatives
Did not like the prescribed method
Need to some time to think
Other (Specify)
D31
Why didn't you obtain the method prescribed to you today?
Method out of stock
Staff not available for the method prescribed
Asked to come after sometimes (eg- after menstrual periods)
Asked/prescribed to get some medical tests done
Referred to other facility for availing the method
Wanted to discuss with spouse/ family
Others (Specify)
D32
During the visit, the method that you chose and obtain was the same method that you wanted to use?
Yes
No
D33
Why didn't you obtain the method you wanted to use?
Not eligible for the method
Medical condition or reason behind
Provider recommended a different method
Method out of stock
Method not available at all at this facility
Staff not available for the method I wanted
Referred to other facility for availing the method
Decided not to adopt the method
Method, I wanted had side-effects
Method, I wanted was Too costly
Other
D34
Has this happened with you before / in past visits in the same facility?
Yes
No
D35
From where are you planning to obtain?
Local pharmacy
Private clinic
Sub-district hospital
District hospital
Medical college
Others (specify)
D36
Did the provider referred you to other facility for method selected by you?
Yes
No
D37
Did the provider ask you to sign any consent form before initiating the method?
Yes
No
D38
During your consultation today, did the provider
D38_1
Explain about other methods?
Yes
No
D38_2
Explain how to use the method?
Yes
No
D38_3
Talk about the effectiveness of the method?
Yes
No
D38_4
Talk about the time for returning the fertility if discontinued?
Yes
No
D38_5
Tell you about the healthy timing and spacing for pregnancy
Yes
No
D38_6
Talk about the possible side effects?
Yes
No
D38_7
Tell you what to do if you have any problems?
Yes
No
D38_8
Tell you when to return for follow-up?
Yes
No
D39
Now, I'd like you to rate the healthcare provider you saw today with respect to the following qualities. For each quality, select the rating that best represents your experience with the healthcare provider.
D39_1
Respecting me as a person
Poor
Fair
Good
Very Good
Excellent
D39_2
Showing care and compassion
Poor
Fair
Good
Very Good
Excellent
D39_3
Letting me say what mattered to me about my birth control method
Poor
Fair
Good
Very Good
Excellent
D39_4
Giving me an opportunity to ask questions
Poor
Fair
Good
Very Good
Excellent
D39_5
Taking my preferences about my birth control seriously
Poor
Fair
Good
Very Good
Excellent
D39_6
Considering my personal situation when advising me about birth control
Poor
Fair
Good
Very Good
Excellent
D39_7
Working out a plan for my birth control with me
Poor
Fair
Good
Very Good
Excellent
D39_8
Giving me enough information to make the best decision about my birth control method.
Poor
Fair
Good
Very Good
Excellent
D39_9
Telling me how to take or use my birth control method most effectively.
Poor
Fair
Good
Very Good
Excellent
D39_10
Telling me the risks and benefits of the birth control method I chose
Poor
Fair
Good
Very Good
Excellent
D39_11
Answering all my questions
Poor
Fair
Good
Very Good
Excellent
D40
ASK THE WOMEN THE QUESTION RELATED TO CONTRACEPTIVE METHODS
D40A
Mala-N
D40A_1
How often one should take the 28-days oral contraceptive pill?
Once a day
Other
Don’t know
D40B
Chhaya
D40B_1
How often one should take the weekly contraceptive pill?
Twice a week for first three months and then once a week
Other
Don’t know
D40C
Condom (male)
D40C_1
How many times can you use one condom?
Only Once
Other
Don’t know
D40D
Condom (female)
D40D_1
What type of lubricant can you use with the female condom?
Any oil or lubricant
Other
Don’t know
D40E
IUCD
D40E_1
What can you do to make sure that your IUCD is in place?
Check strings
Other
Don’t know
D40F
Injectable -Progestin Injectables (Depo-Provera 2-3months)
D40F_1
How long does the injection provide protection from pregnancy?
Till 3 months
Other
Don’t know
D40G
Implants
D40G_1
For how long your implant will provide protection against pregnancy?
3-5 years
Other
Don’t know
D40H
Vasectomy
D40H_1
How long you wait before you rely on vasectomy to protect against pregnancy?
Immediate protection
1-3 months
Only after 3 months or after 30 ejaculations
Others
Don’t know
D40I
Tubectomy
D40I_1
How many days after tubectomy does a woman become completely safe from getting pregnant?
Immediate protection
1-3 months
Only after 3 months or after 30 ejaculations
Others
Don’t know
D40J
LAM
D40J_1
Can you use lactational ammenrhoea method if your menstrual period had returned after delivery?
Yes
No
Patient Satisfaction with family planning services provided.
E01
During the counselling, did the provider referred to you by your name?
Yes
No
E02
What was the duration of the counselling/consultation you had today?
15-20 minutes
More than 30 minutes
Less than 10 minutes
Others(specify)
E03
In your opinion, Was the time spent in consultation/counselling enough to discuss your needs?
Yes
No
E04
Did you feel you had enough privacy during your consultation?
Yes
No
E05
Did you feel comfortable discussing your problems with the doctors, nurses, or other providers without being overheard by anyone who were not involved in your discussion?
Yes
No
E06
In which language, did most of the counselling took place?
English
Local language
E07
Did the provider used any charts/manuals/audio visual aids to explain the services?
Yes
No
E08
What did the provider used for explaining the services?
Charts /Posters
Manuals
Audio- visual aids
Samples
Demonstration
Others(specify)
E09
Were you given any educational / reference materials on family planning to take home?
Yes
No
E10
Did the provider allow you to ask questions about your concerns regarding contraceptive method you opted??
Yes
No
E11
Did the provider answer your questions in a way you understood?
Yes
No
E12
Did the provider answered your questions about your concerns (myths and misconception) regarding contraceptive method you opted
All / most all the questions
Some of the question
Few of the question
None of the question
E13
Were you given enough time to make a final decision on the contraceptive method?
Yes
No
E14
How satisfied are you with the family planning services you received at this facility today? Would you say very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, or very dissatisfied?
Very Satisfied
Satisfied
Neither satisfied nor dissatisfied
Dissatisfied
Very dissatisfied
E15
How clear was the family planning information you received today?
Very clear
Clear
Somewhat clear
Not clear
Not at all clear
E16
Now I am going to ask about some common problems women have at health facilities. As I mention each one, please tell me whether any of these were problems for you today, and if so, whether they were major or minor problems for you.
E16_1
Time you waited to see a provider
Major problem
Minor problem
No problem
Don’t know
E16_2
Provider’s ability to discuss problems or concerns about your method
Major problem
Minor problem
No problem
Don’t know
E16_3
Amount of explanation you received about the problem or treatment
Major problem
Minor problem
No problem
Don’t know
E16_4
Privacy from having others see the examination
Major problem
Minor problem
No problem
Don’t know
E16_5
Privacy from having others hear your consultation discussion
Major problem
Minor problem
No problem
Don’t know
E16_6
Availability of medicines/contraceptives at this facility
Major problem
Minor problem
No problem
Don’t know
E16_7
The hours of service at this facility, i.e., when they open and close
Major problem
Minor problem
No problem
Don’t know
E16_8
The number of days services are available to you
Major problem
Minor problem
No problem
Don’t know
E16_9
How the staff treated you
Major problem
Minor problem
No problem
Don’t know
E16_10
The cleanliness of the facility
Major problem
Minor problem
No problem
Don’t know
E16_11
Cost for services or treatments
Major problem
Minor problem
No problem
Don’t know
E17
Were you charged, or did you pay fees for any services your received or were provided today?
Yes
No
E18
What is the total amount you paid for all services or treatments you received at this facility today?
E19
Were you provided with the contact details regarding helpline number?
Yes
No
E20
Have you have tried to contact/ use the helpline provided?
Yes
No
E21
For what purposes did you contact the helpline provided to you?
To know about family planning services
To know about availability of commodities
To know about how to use a particular method
To know about management of side effects
Was trying causally
Others (specify)
E22
What response did you receive from the helpline?
Didn’t receive any contact as number was not functional
Received satisfactorily response
Received unsatisfactory response
Others (specify)
E23
In general, which of the following statements best describes your opinion of the services you either received or were provided at this facility today READ ALL STATEMENTS, SELECT ONLY ONE,
I AM VERY SATISFIED WITH THE SERVICES I RECEIVED IN FACILITY
I AM MORE OR LESS SATISFIED WITH THE SERVICES I RECEIVED
I AM NOT SATISFIED WITH THE SERVICED I RECEIVED
E24
Based on your experience today, would you return to this facility?
Yes
No
E25
Will you recommend this health facility to a friend or family member?
Yes
No
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