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Household Template New 49 -Form Fill

VILLAGE LOCATION
Q01

DISTRICT NAME
Q02

DISTRICT CODE
Q03

BLOCK NAME
Q04

BLOCK CODE
Q05

SUB-CENTER NAME
Q06

SUB-CENTER CODE
Q07

VILLAGE NAME
Q08

VILLAGE CODE
Q09

AWC NAME
Q10

AWC CODE
Q11

HOUSEHOLD LOCATION

Q11_1

STRUCTURE NO.
Q11_2

HH NO.

Q11_3

TOTAL NUMBER OF ELIGIBLE WOMAN
Q11_4

WOMAN ID
Q11_5

WOMAN ID FROM LISTING
Q11_6

UNIQUE HOUSEHOLD ID
Q11_7

IMPORTANT LANDMARK NEAREST TO THE HOUSEHOLD
Q11_8

NAME OF HEAD OF HOUSEHOLD
Q11_9

NAME OF THE MOTHER
Q11_10

NAME OF THE CHILD
Q11_11

DATE OF BIRTH OF CHILD (DD/MM/YYYY)
Q12

INTERVIEWER VISITS

Q12A

FIRST VISIT

Q12A_1

INTERVIEWER NAME
Q12A_2

INTERVIEWER ID
Q12A_3

DATE OF VISIT
Q12A_4

RESULT CODE
Q12B

SECOND VISIT

Q12B_1

INTERVIEWER NAME
Q12B_2

INTERVIEWER ID
Q12B_3

DATE OF VISIT
Q12B_4

RESULT CODE
Q12C

THIRD VISIT

Q12C_1

INTERVIEWER NAME
Q12C_2

INTERVIEWER ID
Q12C_3

DATE OF VISIT
Q12C_4

RESULT CODE
HOUSEHOLD ROSTER
A01

Please tell me the names of all the persons who usually live in your household, starting with the head of the household. Be sure to include yourself.
A02

What is the relationship of [NAME] to the head of household?

A03

Is [NAME] male or female?
A04

How old is [NAME]?
BIRTH HISTORY
B01

What name was given to your (first/next) baby?

B02

Was this birth a single or multiple?
B03

Is [NAME] a boy or a girl?
B04

In what month and year was [NAME] born?
B05

Is [NAME] still alive?

B06

IF DEAD: How old was (NAME) when he/she died?
B07

What was the cause of [NAME]’s death?
B08

Are you pregnant now?
B09

How many months pregnant are you now?
PREGNANCY AND ANTENATAL CARE
C01

Did you see any health provider for antenatal care for this pregnancy?
C02

Whom did you see? Did you see a…
C03

Where did you receive antenatal care for this pregnancy?
C04

How many months pregnant were you when you first received antenatal care (advice/treatment) for this pregnancy?
C05

How many times did you receive antenatal care during this pregnancy?
C06

As part of your antenatal check-up during this pregnancy, were any of the following done at least once?

C06_1

Were you weighed?
C06_2

Was your blood pressure measured?
C06_3

Did you give a urine sample?
C06_4

Did you give a blood sample?
C06_5

Was your abdomen checked?
C06_6

Were you told your expected delivery date?
C06_7

Were you advised to deliver in a hospital or health facility?
C06_8

Did you get an ultrasound?
C07

During your pregnancy with [CHILD NAME], were you given an injection to prevent you and the baby from getting tetanus?
C08

During this pregnancy, how many times did you get a tetanus injection?
C09

Were you given any Iron Folic Acid (IFA) tablets during your pregnancy with [CHILD’s NAME]?
C10

How many tablets did you receive in total during your whole pregnancy with [CHILD’s NAME]?
C11

From whom did you get Iron Folic Acid (IFA) tablets?
C12

During the whole pregnancy, how many tablets did you consume?
C13

When did you first start consuming these tablets (during which month of pregnancy)?
C14

Other than the iron tablets that I showed you,  did you consume iron syrup, iron tablets, iron capsules or any other iron formulation that you obtained from a chemist or doctor or anywhere else?
C15

Did you receive any food from the Anganwadi centre during this pregnancy?
C16

Now I would like to ask you about anything specific that you did to prepare for the [name’s]a birth/delivery.

C16_1

Obtain a new blade to cut the cord?

C16_2

Obtain a new/clean thread to tie the cord?
C16_3

Obtain clean cloth for drying the baby?
C16_4

Save money for the delivery?
C16_5

Identify health facility for the delivery or in case of emergency during delivery?
C16_6

Obtain phone number of health facility for the delivery or in case of emergency during delivery?
C16_7

Identify a person to accompany you to healthcare facility?
C16_8

Identify and arrange for a skilled birth attendant, such as an ANM, trained DAI to be present during childbirth?
C17

Now I would like to ask about any plans for transportation that you might have made to go to a health facility for the delivery or in case of emergency. Did you

C17_1

Did  you or your family identify a vehicle for transportation?
C17_2

If so, did you have the number of the driver of that vehichle?
C17_3

Do you have the  number of ambulance service?
C17A

If yes, what was the number of the ambulance service?

C17B

Did you have the number of an ASHA or AWW or ANM to call for the assistance in case transportation was not available?
C17C

If yes, whose number do you have?
C18

Prior to delivery, did you plan or intend to deliver [CHILD NAME] at home or in a healthcare facility?
C19

Were you aware of the Janani Suraksha Yojana (JSY) scheme that provides incentives for mothers to give birth in a facility?
C20

Did you discuss plans for your delivery with [CHILD NAME]’s father?
C21

Did you discuss plans for your delivery with your Mother-in-Law?

LABOR AND DELIVERY
D01

Did you go to your mother’s or other relative’s house to have [CHILD NAME]?
D02

Was this house in the village/town where you usually live?
D03

At what month of pregnancy did you go to this home?
D04

How long after delivery did you get back here?
D05

How many months pregnant were you when [CHILD NAME] was born?
D06

Where did you deliver [CHILD NAME]?
D07

Earlier, you said you planned to deliver at home, but you delivered in a facility. Why did you change your mind?

D08

Earlier, you said you planned to deliver at a facility, but you delivered at home. Why did you change your mind?

D09

Who conducted the delivery of [CHILD’S NAME]?
D10

Who went with you to the health facility for your delivery?
D11

What mode of transportation did you take to get to the healthcare facility?
D12

How long did it take you to reach the healthcare facility?
D13

How long did you stay at the healthcare facility after [CHILD NAME] was delivered?
D14

Were you promised money or an incentive for delivery of your baby in a healthcare facility through the JSY program?
D15

Did you receive the payment?
D16

First, let me start with knowledge. Could you name some of the danger signs or symptoms during pregnancy/delivery that would indicate the need for a pregnant woman to seek medical care immediately?
D17

Now I would like to ask about your expreince. Did you experience any of the following symptoms during your pregnancy with [CHILD NAME] or during delivery of the child?

D17A

Did you experience

D17A_1

Prolonged labor (>12 hours)
D17A_2

Excessive bleeding
D17A_3

Convulsions
D17A_4

Swelling of the hands, body or face
D17A_5

Fever
D17A_6

Vaginal discharge/foul smelling discharge

D17A_7

Severe pain in the lower abdomen
D17B

Did you seek treatment for ______________?

D17B_1

Prolonged labor (>12 hours)
D17B_2

Excessive bleeding
D17B_3

Convulsions
D17B_4

Swelling of the hands, body or face
D17B_5

Fever
D17B_6

Vaginal discharge/foul smelling discharge

D17B_7

Severe pain in the lower abdomen
D17C

From where did you seek treatment?

D17C_1

Prolonged labor (>12 hours)
D17C_2

Excessive bleeding
D17C_3

Convulsions
D17C_4

Swelling of the hands, body or face
D17C_5

Fever
D17C_6

Vaginal discharge/foul smelling discharge

D17C_7

Severe pain in the lower abdomen
D18

You mentioned that you experienced some symptoms during pregnancy or delivery.

D19

Did an ASHA or AWW advise you to seek treatment for these symptoms?

D20

If yes, did the ASHA or AWW advise you where to go?
D21

Did an ASHA or AWW accompany you or take you to seek treatment?
D22

Now I would like to ask you about the baby and cord care for the baby.
D23

What instrument was used to cut the umbilical cord?
D24

Where did you get the instrument from?
D25

Did you purchase the instrument or did you bring one you already had at home?

D26

What was used to tie the cord?
D27

Where did you get the [answer to F36] from?
D28

Did you purchase the [answer to F36] or did you bring one from home?

D29

Was anything applied to the cord after cutting and tying?
D30

Was anything applied to the umbilicus after the cord dropped off?
D31

What was applied to the cord after cutting and tying, and/or to the umbilicus after the cord dropped off?
D32

Did the ASHA or AWW talk to you about how you should take care of the cord?
D33

Do you know if something should be applied to the cord or umbilicus after cutting it?
D34

Can you tell me why nothing should be applied to the cord or umbilicus after cutting it?
D35

How soon after the delivery was [CHILD NAME] given (his/her) first bath?
D36

Did the ASHA or AWW talk with you about when you should first bathe the baby after birth
D37

How soon after delivery do you think a baby should first be bathed?
D38

What are the benefits of waiting for 24 hours before bathing the baby?
D39

When was the child weighed for the first time?
D40

What was the weight of [CHILD NAME]?

D41

Was [CHILD NAME] small or weak when he/she was born?
D42

Did an ASHA or AWW tell you that [CHILD NAME] was small or weak?
D43

Did an ASHA or AWW visit your home to provide you with specific instructions or guidance for how to care for a small or weak child?
D44

Have you heard of Skin to Skin Care or Kangaroo Care? PROBE: kangaroo care refers to the infant being placed unclothed on the mother’s chest with skin to skin contact under a blanket or some clothing.

D45

After delivery, did you or any health worker or someone else place [CHILD NAME] unclothed in skin-to-skin contact on mother’s chest or abdomen under a blanket or some clothing? 
D46

Did you ever breastfeed [CHILD NAME]?
D47

Why did you never breastfeed [CHILD NAME]?
D48

How long after birth did you first put [CHILD NAME] to the breast?
D49

Did an ASHA or AWW talk with you about when you should first put the baby to breast?
D50

How soon after delivery do you think a baby should be put a baby to breast?
D51

What are the benefits of feeding the baby immediately or within one hour?
D52

Was [CHILD NAME] given anything other than breast milk on the first day?
D53

What was [CHILD NAME] given?
D54

Before you were discharged from [INSTITUTION] after [CHILD NAME] was born, did a doctor or nurse check on your health?
D55

Did they do any of the following

D55_1

Check your blood pressure?
D55_2

Measure temperature?
D55_3

Check for excessive bleeding
D56

Before you were discharged from [INSTITUTION] after [CHILD NAME] was born, did a doctor or nurse check on [CHILD NAME] health?
D57

Did they do any of the following

D57_1

Examine the baby’s body
D57_2

Observe the umbilical cord
D57_3

Observe you breastfeeding the baby
D57_4

Check the baby’s temperature

D58

Before you were discharged from [INSTITUTION] after [CHILD NAME] was born, did you receive advice from a doctor, nurse, ANM or someone at the facility on caring for yourself?
D59

Before you were discharged from [INSTITUTION] after [CHILD NAME] was born, did you receive advice from a doctor, nurse, ANM or someone at the facility on caring for your new born?
D60

Before you were discharged did a Doctor, nurse, ANM or someone advise you about postpartum IUD?

POSTPARTUM AND WELL-BABY CARE
E01

I would like to start with your knowledge. Can you name some of the danger signs or symptoms that a woman might have within 6 weeks (or one-and-a-half months) after delivery that would require her to seek medical care?
E02

Now I would like to ask about your expreince. Did you experience any of the following symptoms within the first 6 weeks (or one-and-a-half months)?

E02A

Did you experience

E02A_1

Vaginal bleeding
E02A_2

Severe pain in lower abdomen
E02A_3

Fever
E02A_4

Foul smelling vaginal discharge
E02B

Did you seek treatment or assistance with a health worker for _________?

E02B_1

Vaginal bleeding
E02B_2

Severe pain in lower abdomen
E02B_3

Fever
E02B_4

Foul smelling vaginal discharge
E02C

From where did you seek treatment?

E02C_1

Vaginal bleeding
E02C_2

Severe pain in lower abdomen
E02C_3

Fever
E02C_4

Foul smelling vaginal discharge
E03

You mentioned that you experienced some symptoms during the first 6 weeks after delivery.
E04

Did an ASHA or AWW advise you to seek treatment for these symptoms?

E05

If yes, did the ASHA or AWW advise you where to go?
E06

Did an ASHA or AWW accompany you or take you to seek treatment?
E07

Can you name some of the danger signs or symptoms that an infant might have within the first month after delivery that would require seeking medical care?
E08

Did [CHILD NAME] experience any of the following symptoms during the first month?

E08_1

Loss of interest in breastfeeding?
E08_2

Difficult/rapid breathing?
E08_3

Cold to touch?
E08_4

Drowsy/difficult to awaken?
E08_5

Jaundice
E08A

Did you seek treatment or assistance with a health worker for _________?

E08A_1

Loss of interest in breastfeeding?
E08A_2

Difficult/rapid breathing?
E08A_3

Cold to touch?
E08A_4

Drowsy/difficult to awaken?
E08A_5

Jaundice
E08B

From where did you seek treatment?

E08B_1

Loss of interest in breastfeeding?
E08B_2

Difficult/rapid breathing?
E08B_3

Cold to touch?
E08B_4

Drowsy/difficult to awaken?
E08B_5

Jaundice
E09

You mentioned that your child  experienced some symptoms during the first month.
E10

Did an ASHA or AWW advise you to seek treatment for [CHILD NAME] for these symptoms?

E11

If yes, did the ASHA or AWW advise you where to take the child?
E12

Did an ASHA or AWW accompany you or your child to seek treatment?
E13

Are you still breastfeeding [CHILD NAME]?
E14

How old was [CHILD NAME] when you stopped breastfeeding?
E15

Why did you stop breastfeeding [CHILD NAME]?
E16

For how many months did you exclusively breastfeed that is no other food or liquid was given to [CHILD NAME]?
E17

During the time that you exclusively breastfed, did you give water to the baby?
E18

How many times did you breastfeed [CHILD NAME] in the last 24 hours?
E19

Now I would like to ask you about other liquids [CHILD NAME] drank yesterday during the day or at night.

E19_1

Plain water?
E19_2

Commercially produced infant formula milk?
E19_3

Any other kind of milk (tinned, powdered, or fresh animal milk)?
E19_4

Buttermilk/Lassi?
E19_5

Fruit juice?
E19_6

Tea or coffee?
E19_7

Sodas like Pepsi, Coke, Orange drink?
E19_8

Clear broth/rice water/soup/boiled water?
E19_9

Thin porridge?
E20

Does [CHILD NAME] eat any solid, semi-solid or soft foods?
E21

When did [CHILD NAME] begin eating semi-solid, soft foods?
E22

Have you ever had concerns about feeding your child solid or semi-solid foods?
E23

If yes, what were those concerns?
E24

Did the ASHA/AWW ever talk to you about those concerns?
E25

Did an ASHA or AWW talk to you about when should you start feeding a child solid or semi-solid foods?
E26

Do you know at what age a child should start being fed solid or semi-solid foods?
E27

Can you tell me why a child should be fed solid or semi-solid foods after completing starting at age 6 months ?
E28

Now I would like to ask you about the food [CHILD NAME] ate yesterday during the day or at night, either separately or combined with other foods.

E29

Yesterday, did [CHILD NAME] eat any:

E29_1

Porridge or gruel (Rice/Khichdi)?
E29_2

Commercially fortified baby food such as Cerelac or Farex?
E29_3

Bread, roti, chapati?
E29_4

Daal (Foods made with lentils or beans)?
E29_5

Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?
E29_6

White potatoes, white yams, manioc, cassava, or any other foods made from roots?
E29_7

Any dark green leafy vegetables?
E29_8

Ripe mangoes, ripe papayas, or (insert other local vitamin a-rich fruits)?
E29_9

Any other fruits or vegetables?
E29_10

Meat/Chicken/Fish ?
E29_11

Egg?
E29_12

Nuts?

E29_13

Purchased snack foods (chips, chanachur, biscuit, chocolate/candies)?
E29_14

Curd/cheese
E29A

How many days was this food given to child in the past 7 days?

E29A_1

Porridge or gruel (Rice/Khichdi)?
E29A_2

Commercially fortified baby food such as Cerelac or Farex?
E29A_3

Bread, roti, chapati?
E29A_4

Daal (Foods made with lentils or beans)?
E29A_5

Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?
E29A_6

White potatoes, white yams, manioc, cassava, or any other foods made from roots?
E29A_7

Any dark green leafy vegetables?
E29A_8

Ripe mangoes, ripe papayas, or (insert other local vitamin a-rich fruits)?
E29A_9

Any other fruits or vegetables?
E29A_10

Meat/Chicken/Fish ?
E29A_11

Egg?
E29A_12

Nuts?

E29A_13

Purchased snack foods (chips, chanachur, biscuit, chocolate/candies)?
E29A_14

Curd/cheese
E29B

How many days was this food available/prepared in the household in the past 7 days?

E29B_1

Porridge or gruel (Rice/Khichdi)?
E29B_2

Commercially fortified baby food such as Cerelac or Farex?
E29B_3

Bread, roti, chapati?
E29B_4

Daal (Foods made with lentils or beans)?
E29B_5

Pumpkin, carrots, squash, or sweet potatoes that are yellow or orange inside?
E29B_6

White potatoes, white yams, manioc, cassava, or any other foods made from roots?
E29B_7

Any dark green leafy vegetables?
E29B_8

Ripe mangoes, ripe papayas, or (insert other local vitamin a-rich fruits)?
E29B_9

Any other fruits or vegetables?
E29B_10

Meat/Chicken/Fish ?
E29B_11

Egg?
E29B_12

Nuts?

E29B_13

Purchased snack foods (chips, chanachur, biscuit, chocolate/candies)?
E29B_14

Curd/cheese
E30

Excluding oil for cooking, in the last 24 hours, did you add oil/ghee/butter to the food you gave [CHILD NAME]?
E31

How many times did (NAME) eat solid, semi- solid, or soft foods other than liquids yesterday during the day or at night?
E32

Of the times the child ate these foods yesterday, how many times was the child fed from a separate bowl?
E33

How many of of all the meals child ate yesterday included roti, rice, or porridge/gruel (khichdi)?
E34

How many katoris of food do you think the child ate yesterday?

E35

In the past 3 months, how many times did you receive any food for [CHILD NAME] from the Anganwadi centre?
E36

In the past 3 months, how many times did you receive any food for yourself for lactation from the Anganwadi centre after delivery?
E37

The last month you received food from the AWC for the child and/or yourself, how much rice did you receive?

E38

The last month you received food from the AWC for the child or yourself, how much daal did you receive?

E39

A 4 month old baby seems thirsty during summer months. Is it okay to give the baby some water to drink?
E40

For how many months after birth should a child receive only breast milk to drink?
E41

When do you usually wash your hands during a typical day?
E42

Have you used soap to wash your hands at least once since this time yesterday?
E43

The last time [CHILD NAME] passed stools, what was done to dispose of the stools?
IMMUNIZATIONS
F01

Did [CHILD NAME] ever receive any vaccinations to prevent (him/her) from getting diseases, including vaccinations received in a Pulse Polio program?
F02

What is the main reason that [CHILD NAME] has not received any vaccinations?
F03

Do you know where to go to get vaccinations for your child?
F04

Where would you go to have your baby immunized? What kind of place would that be?
F05

Do you have a card where [CHILD NAME]’s vaccinations are written down?
F06

COPY VACCINATION DATE FOR EACH VACCINE FROM THE CARD.

F06_1

BCG

F06_2

POLIO 0
F06_3

POLIO 1
F06_4

DPT 1
F06_5

POLIO 2
F06_6

DPT 2

F06_7

POLIO 3

F06_8

DPT 3

F06_9

MEASLES

F06_10

VITAMIN A

F07

Please tell me if [CHILD NAME] received any of the following vaccinations

F07_1

A BCG vaccination against tuberculosis, that is, an injection in the arm or shoulder that usually causes a scar?
F07_2

A Polio vaccine?
F07_3

Was the first polio vaccine received in the first two weeks after birth?
F07_4

How many times was the polio vaccine received?

F07_5

A DPT vaccination, that is, and injection given in the thigh or buttocks, sometimes at the same time as polio drops?
F07_6

How many times was a DPT vaccination received?
F07_7

If the DPT3 was given, on which date was it given?
F07_8

The first dose of Vitamin A?
F07_9

An injection to prevent measles?
REPRODUCTIVE HEALTH
G01

Which ways or methods have you heard about?

G01_1

FEMALE STERILIZATION Women can have an operation to avoid having any more children.
G01_2

MALE STERILIZATION Men can have an operation to avoid having any more children.
G01_3

MALA-D OR PILL Women can take a pill every day or every week to avoid becoming pregnant.
G01_4

IUD OR LOOP or Copper T Women can have a loop or coil placed inside them by a doctor or a nurse.
G01_5

INJECTABLES Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
G01_6

CONDOM OR NIRODH Men can put a rubber sheath on their penis before sexual intercourse.
G01_7

EMERGENCY CONTRACEPTION Women can take pills up to three days after sexual intercourse to avoid becoming pregnant.
G01_8

Have you heard of any other ways or methods that women or men can use to avoid pregnancy?
G02

Have you ever had concerns about the use of IUDs?
G03

If yes, what concerns?
G04

did the ASHA or AWW ever talk to you about these concerns?
G05

Are you currently doing something or using any method to delay or avoid getting pregnant?
G06

Which method are you using?
G07

Have you had any difficulties in getting this contraception?
G08

If yes, what difficulties did you face?

G09

Do you plan to use a contraceptive  method to delay or avoid pregnancy sometime during the next 12 months?
G10

Which contraceptive method would you use?
G11

Has an FLW  talked with you about how soon you can get pregnant again after delivery?
G12

Do you know how soon you can get pregnant again after delivery?
G13

Would you say that using contraception is mainly your decision, mainly your husband's decision, or did you both decide together?
G14

Do you think there are any benefits of birth spacing?
G15

What are the benefits of birth spacing?
G16

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?
G17

If prefer another child, how many more children would you like to have ?
G18

During the past three months, have you talked with your husband about family planning?
G19

Why haven’t you talked with your husband about family planning?
G20

During the past three months, have you talked with your mother in law about family planning?
INTERACTIONS WITH FRONTLINE WORKERS
H01

During your pregnancy with (CHILD NAME), did you receive any advice from an ASHA/ANM/AWW related to getting TT injections?
H02

During your pregnancy with (CHILD NAME), did you receive any advice from the ASHA/ANM/AWW on taking IFA tablets ?
H03

If yes, did they tell you how many pills are to be consumed?
H04

If so, how many pills did they tell you take ?
H05

Did the ASHA/ANM/AWW tell you about any unintended effects that consuming IFA tablets can have on your health?
H06

If yes, what unintended effects did she discuss with you?
H07

During the last three months of this pregnancy with [CHILD NAME], did an ASHA visit you at your home to talk about your pregnancy?
H08

How many times did the ASHA visit you at home during those last three months?
H09

During the last three months of this pregnancy with [CHILD NAME], did an ANM visit you at your home to talk about your pregnancy?
H10

How many times did the ANM visit you at home during those last three months?
H11

During the last three months of this pregnancy with [CHILD NAME], did an AWW visit you at your home to talk about your pregnancy?
H12

How many times did the AWW visit you at home during those last three months?
H13

During any of these discussions during last 3 months of your pregnancy with (CHILD NAME), did you receive any advice from the ASHA/ANM/AWW related to being prepared for delivery like specific preparations you need to make to be ready for the birth of the child?
H14

During any of these discussions during last 3 months of your pregnancy with [CHILD NAME], what advice did you receive from the ASHA/ANM/AWW related to being prepared for delivery?

H14_1

Obtain a new blade to cut the cord?
H14_2

Obtain a new/clean thread to tie the cord?
H14_3

Obtain clean cloth for drying the baby?
H14_4

Save money for the delivery?
H14_5

Identify health facility for the delivery or in case of emergency during delivery?
H14_6

Identify phone number of health facility for the delivery or in case of emergency during delivery?
H14_7

Identify a person to accompany you to healthcare facility?
H14_8

Identify and arrange for a skilled birth attendant, such as an ANM, DAI to be present during childbirth?
H15

During any of these discussions during last 3 months of your pregnancy with (CHILD NAME), did you receive any advice from the ASHA/ANM/AWW related to caring for your newborn immediately after birth like types of things you need to do to take care of the newborn?
H16

During any of these discussions during last 3 months of your pregnancy with [CHILD NAME], what advice did you receive on caring for your newborn immediately after birth from the ASHA/ANM/AWW?

H16_1

How to keep the cord clean?
H16_2

How to keep the baby warm?
H16_3

Skin to skin contact? PROBE: It refers to the infant being placed unclothed on the mother’s chest with skin to skin contact under a blanket or some clothing.
H16_4

Putting baby to breast immediately after delivery?
H16_5

Keeping the baby clean
H17

During any of these discussions during last 3 months of your pregnancy with (CHILD NAME), did the ASHA/ANM/AWW ANM talk with you about danger signs that you may experience before or after delivery that require to see a doctor immediately?
H18

During any of these discussions during last 3 months of your pregnancy, what advice did you receive on the danger signs that you may experience after delivery?

H18_1

Excessive Vaginal bleeding?
H18_2

Severe pain in lower abdomen?
H18_3

Fever?
H18_4

Foul smelling vaginal discharge?
H19

During any of these discussions during the last three months of your pregnancy with (CHILD NAME), did the ASHA/ANM/AWW ANM talk with you about danger signs that your child may experience after birth that require to see a doctor immediately?
H20

During any of these discussions during last 3 months of your pregnancy, what advice did you receive on the danger signs that your child may experience after delivery?

H20_1

Loss of interest in breastfeeding?
H20_2

Difficult/rapid breathing?
H20_3

Cold to touch?
H20_4

Drowsy/difficult to awaken?
H21

Who was present at the time of your delivery of [CHILD NAME]?

H21_1

ASHA
H21_2

AWW
H21_3

ANM
H22

In the first 24 hours after delivery, did an ASHA/AWW/ANM come to visit you to discuss your health or your child’s health?
H23

If yes, Who came to visit you and the baby? Was it the ASHA, AWW, ANM?

H23_1

ASHA
H23_2

AWW
H23_3

ANM
H24

How many times did the ASHA/ AWW/ ANM visit you?
H25

After the first 24 hours after delivery but before the first week, did an ASHA/AWW/ANM come to visit you to discuss your health or your child’s health?
H26

If yes, Who came to visit you and the baby? Was it the ASHA, AWW, ANM?

H26_1

ASHA
H26_2

AWW
H26_3

ANM
H27

How many times did the ASHA/ AWW/ ANM visit you?
H28

After the first week after delivery but before the first month, did an ASHA/AWW/ANM come to visit you to discuss your health or your child’s health?
H29

If yes, Who came to visit you and the baby? Was it the ASHA, AWW, ANM?

H29_1

ASHA
H29_2

AWW
H29_3

ANM
H30

How many times did the ASHA/ AWW/ ANM visit you?
H31

What were the topics  discussed with an ASHA, ANM, AWW during any of the visits in the first month after [CHILD NAME] was delivered?

H31_1

Received advice on when to breastfeed?
H31_2

received advice on how to breastfeed
H31_3

Received advice on skin-to-skin (kangaroo) care?
H31_4

Received information about danger signs or symptoms for you?
H31_5

Received information about danger signs or symptoms for your newborn?
H31_6

Received advice on how to keep baby warm
H31_7

Received advice on when to bathe the baby
H32

After the first month until now, did an ASHA/AWW/ANM come to visit you in your home to discuss your health or your child’s health?
H33

If yes, Who came to visit you and the baby? Was it the ASHA, AWW, ANM?
H34

How many times did the ASHA/ AWW/ ANM visit you in your home?
H35

During any of the times they visited you at home, did the ASHA/AWW/ANM ever observe when you were breast feeding (NAME)?
H36

During any of the times they visited you at home, did the ASHA/AWW/ANM ever tell you how many months to exclusively breastfeed the child?
H37

During any of the times they visited you at home, did the ASHA, AWW or ANM did they tell you about the importance of comprehensive immunization?
H38

Which immunizations did they discuss with you?
H39

During any of the times they visited you at home, Did the ASHA, AWW,ANM, talk to you or your husband about the possibility of using methods to delay the next child or stop having children?
H40

Which birth control methods were discussed during any of the conversations with an ASHA, ANM, AWW after [CHILD NAME] was delivered?

H40_1

Male sterilization
H40_2

Female sterilization/tubal ligation
H40_3

Injectables
H40_4

IUD or loop
H40_5

CONDOMS

H40_6

PILLS
H41

During any of the times they visited you at home,, has the ASHA, AWW or ANM, ever demonstrated proper hand washing using water or soap or something else to you?
H42

During any of the times they visited you at home, did the ASHA, AWW or ANM advise you on when to wash hands?
H43

During any of the times they visited you at home, any of these visits, did an ASHA, AWW or ANM discuss topics related to infant and young child feeding?
H44

If yes, how old was the child when first such visit took place?
H45

How many times did an ASHA, AWW or ANM visit to discuss these topics?
H46

During any of these visits, which topics related to infant and young child feeding were discussed with the ASHA, AWW or ANM?

H46_1

Complementary feeding starting at age 6 months

H46_2

How much to feed the baby and the types of food to feed the baby

H46_3

On demand breast feeding until 24 months
H47

During any of these visits, did the ASHA, AWW or ANM ask you what you had cooked that day?
H48

Did the ASHA, AWW or ANM tell you what types of food you should feed your child?
H49

If yes, what foods did they tell you to feed the child?
H50

If yes, how many times per day?

H51

Did they show you, using a katori, how much to feed the child for each meal?
H52

Did they advise you to feed the child from our plate or to feed the child out of a separate plate or bowl?
H53

Now think about the last time an AWW, ASHA, or AWW visited you at home to discuss your health or the health of your child:

H53_1

ASHA
H53_2

AWW
H53_3

ANM
H54

About how long did she/they spend at your home during that last visit (in minutes)?
H55

How did this time compare to previous visits - was the visit about the same, longer, or shorter, than any typical visit by the ASHA, AWW or FLWANM?
H56

Did the FLW talk to anyone in the household other than you? If so, who? 
H57

Did the ASHA, AWW, ANM use any job aid tools during this visit?
H58

If yes, what tools did she use?

H58_1

MOBILE PHONES WITH AUDIO (PROBE FOR DR ANITA
H58_2

PLASTIC PICTURE CARDS (describe mobile ku nji cards)
H58_3

POSTERS/PAMPHLETS/BOOKS
H58_4

WALL STICKERS

H58_5

UTERUS MODEL
H58_6

KATORA/SPOON
H58_7

MALA-D
H58_8

COPPER-T
H58_9

ORS SACHET
H58_10

IFA TABLET
H59

Did you find the usage of these tools useful?
H60

Which of these tools did you find most useful?
H61

Which tools provided you with new information you did not already know?
H62

[Interviewer observation] Is there a wall sticker in the home of the type used by FLWs to track progress of the women?”
H63

During your pregnancy, delivery, or since birth of [CHILD] have the AWW and ASHA ever come together and done a home visit to talk about your health or your childs health?
H64

During your pregnancy, delivery, or since birth of [CHILD] has the ANM ever come together with the AWW or ASHA and done a home visit to talk about your health or your child’s health?
H65

Thinking about your interactions with the AWW/AHSA during your pregnancy, delivery, or since birth of [CHILD], please tell me how often she did the following: (ask all of the time, most of the time, some of the time, none of the time)

H65_1

Allowed you to express your opinion on how to take care of your health or your child’s healt h

H65_2

Remembered details of your health or your child’s health

H65_3

Answered questions you have about your health or your child’s health or addressed any issues you have
H65_4

Gave you new and useful information that you did not already know
H65_5

Suggested issues that she would follow-up with you, and arranged a follow-up time
H65_6

Assured you that she would not reveal the information shared by you with anyone else
H65_7

Explained why she was recommending practicing certain behaviours for your and your child’s health
QUALITY OF CARE (FRONT LINE WORKERS)
I01

DID THE RESPONDENT EVER MEET WITH AN AWW, ANM OR ASHA DURING PREGNANCY OR DELIVERY OR SINCE THE CHILD WAS BORN?
I02

Whom did you see the most during you pregnancy and after the birth of your child, the ASHA or Anganwadi Worker?
I03

I’d now like to ask you about the Anganwadi worker.

I03A

AWW

I03A_1

Treats you with respect – Agree or disagree
I03A_2

Is knowledgeable about your health needs during pregnancy and delivery – Agree or disagree
I03A_3

Is knowledgeable about the health needs of babies – Agree or disagree
I03A_4

Directs you to appropriate health service providers – Agree or disagree
I03A_5

Responds quickly to emergency situations – Agree or disagree
I03A_6

Is available when you need her- Agree or disagree
I03B

ASHA

I03B_1

Treats you with respect – Agree or disagree
I03B_2

Is knowledgeable about your health needs during pregnancy and delivery – Agree or disagree
I03B_3

Is knowledgeable about the health needs of babies – Agree or disagree
I03B_4

Directs you to appropriate health service providers – Agree or disagree
I03B_5

Responds quickly to emergency situations – Agree or disagree
I03B_6

Is available when you need her- Agree or disagree
ANTHROPOMETRY AND INTERVIEWER OBSERVATIONS
J01

IS FOCAL CHILD ALIVE?
J02

RECORD AGE
J03

IS FOCAL CHILD OLDER THAN 5 MONTHS AND 30 DAYS AND NO MORE THAN 11 MONTHS AND 30 DAYS OLD

J04

MEASURE ONLY FOCAL CHILD. MEASURE CHILDREN LYING DOWN.

J05

RECORD DATE OF BIRTH
J06

RECORD AGE OF [CHILD NAME]
J07

RECORD WHETHER WEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
J08

RECORD WEIGHT (G)

J08A

FIRST MEASUREMENT
J08B

SECOND MEASUREMENT
J09

RECORD WHETHER HEIGHT WAS TAKEN OR NOT AND REASON WHY NOT.
J10

RECORD HEIGHT

J10A

FIRST MEASUREMENT
J10B

SECOND MEASUREMENT
J11

DOES THE AREA IMMEDIATELY AROUND THE HOUSE NEED TO BE SWEPT AND CLEANED?
J12

IS THERE HUMAN FECES AROUND THE HOUSE OR IN THE COMPOUND?
J13

IS THERE ANIMAL FECES (CHICKEN, GOAT, ETC.) AROUND THE HOUSE OR IN THE COMPOUND?
J14

IS THERE ANIMALS (CHICKEN, GOAT, ETC.) WITHIN THE HOUSE?
J15

IS THERE GARBAGE AROUND THE HOUSE (OPEN GARBAGE CAN, GARBAGE ON THE GROUND) OR IN THE COMPOUND?
J16

WHAT IS THE GENERAL APPEARANCE OF THE INTERIOR OF THE HOUSE?
J17

DOES THE FLOOR INSIDE THE HOUSE NEED TO BE SWEPT?
DEMOGRAPHICS
K01

What is your religion?
K02

What is your caste?
K03

CODE WHETHER THE CASTE IS A SCHEDULED CASTE, SCHEDULED TRIBE, OTHER BACKWARD CASTE, OR SOMETHING ELSE.
K04

What is your current marital status?
K05

Did your husband ever attend school?
K06

What is the highest standard or class your husband completed?
K07

In the past 12 months, has your husband been employed?
K08

What is your husband’s main occupation?
K09

How old were you when you got married?
K10

Do you know how to read and write?
K11

Have you ever attended school?
K12

What is the highest standard or class you completed?
K13

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. In the last seven days, have you done any of these things or any other work?
K14

Have you done any work in the last 12 months?
K15

What is your occupation, that is, what kind of work do you mainly do?
K16

Do you do any of this work for your own family or for someone else?
K17

Are you paid in cash or kind for this work, or are you not paid at all?
K18

Who in your household decides how the money that you earn should be used: you, your husband, you and your husband jointly, or someone else?
K19

Who in your household usually makes the following decisions: you, your husband, you and your husband jointly, or someone else?

K19_1

Decisions about health care for yourself?
K19_2

Decisions about health care for your child?
K19_3

Decisions about making major household purchases?
K20

Are you usually allowed to go to the following places alone, only with someone else, or not at all?

K20_1

To the market?
K20_2

To the health facility?
K20_3

To places outside this (village/community)?
K21

How long does it take you to walk from home to the village center/panchayat?
K22

What is the closest type of healthcare facility where women go to give birth?
K23

How long would it take you to reach the facility?

K24

Can it be difficult to reach this facility during rainy seasons due to flooding?
K25

Now, I will ask some questions about food available to eat in your household.

K26

In the last four weeks, did you or any household member go to sleep at night hungry because there was not enough food?
K27

In the last four weeks, how often did this happen—once or twice, three to ten times or more than ten times?
K28

Do you have a mobile phone that you use for yourself?
K29

If yes, is the phone self owned or shared?
K30

If shared, with whom is it shared?
HOUSEHOLD CHARACTERISTICS
L01

Does your household own this house or any other house?
L02

How many members are there in the household?
L03

LOOK AT THE FLOOR AND CODE THE MAIN MATERIAL OF THE FLOOR
L04

LOOK AT THE ROOF AND CODE THE MAIN MATERIAL OF THE ROOF
L05

LOOK AT THE EXTERIOR WALLS AND CODE THE MAIN MATERIAL OF THE WALLS
L06

TYPE OF WINDOWS
L07

How many rooms in this house are used for sleeping?
L08

What is the main source of drinking water for members of your household?
L09

Do you treat your water in any way to make it safer to drink?
L10

What do you usually do to the water to make it safer to drink?
L11

What kind of toilet facility do members of your household usually use?
L12

Do you share this toilet facility with other households?
L13

How many households use this toilet facility?
L14

In the past week has anyone in your household including children defecated in the open- for example in the field or in the river?
L15

Do you have a separate room which is used as a kitchen?
L16

What type of fuel does your household mainly use for cooking?
L17

What is the main source of lighting in this household?

L18

Does your household have

L18_1

Electricity

L18_2

A mattress

L18_3

A pressure cooker

L18_4

A chair

L18_5

A cot or bed

L18_6

A table

L18_7

An electric fan

L18_8

A radio or transistor

L18_9

A black and white television

L18_10

A colour television

L18_11

A sewing machine

L18_12

A mobile telephone

L18_13

Any other type of telephone

L18_14

A computer

L18_15

A refrigerator

L18_16

A watch or clock

L18_17

A bicycle

L18_18

A motorcycle or scooter

L18_19

An animal-drawn cart

L18_20

A car

L18_21

A water pump

L18_22

A thresher

L18_23

A tractor

L19

Does any member of this household have a bank account or post-office account?
L20

Is any member of this household covered by a health scheme or health insurance?
L21

What type of health scheme or health insurance?
L22

Does this household have a BPL card/coupon?
L23

Does this household have a RSBY card?
L24

Does this household have a NREGA card?
L25

Those are all the questions I have. Thank you so much for taking the time to speak with me.
L26

Please rate your perceptions of the following qualities of the respondent, the interviewing situation, and the data. In your opinion, the respondent

L26_1

Was truthful, accurate
L26_2

Answered questions on her own
L26_3

Was able to understand Hindi well
L26_4

Was interviewed without interruptions
L26_5

Please rate your opinion about the overall quality of the data.