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Household Template 34 -Form Fill

IDENTIFICATION AND INTERVIEW ELIGIBILITY
Q01

NAME OF DISTRICT
Q02

CODE OF DISTRICT
Q03

NAME OF BLOCK
Q04

CODE OF BLOCK
Q05

VILLAGE/URBAN AREA NAME
Q06

CLUSTER CODE
Q07

NAME OF HOUSEHOLD HEAD
Q08

STRUCTURE NUMBER
Q09

HOUSEHOLD ID NUMBER
Q10

INTERVIEWER VISITS -1

Q10_1

DATE
Q10_2

TIME STARTED
Q10_3

TIME FINISHED
Q10_4

INTERVIEWER’S NAME
Q10_5

RESULT*
Q11

INTERVIEWER VISITS -2

Q11_1

DATE
Q11_2

TIME STARTED
Q11_3

TIME FINISHED
Q11_4

INTERVIEWER’S NAME
Q11_5

RESULT*
Q12

INTERVIEWER VISITS -3

Q12_1

DATE
Q12_2

TIME STARTED
Q12_3

TIME FINISHED
Q12_4

INTERVIEWER’S NAME
Q12_5

RESULT*
HOUSEHOLD ROASTER
A01

ID of household member
A02

Name of the person
A03

Sex
A04

Age of (Name)
A05

Relationship to Household head
A06

Does (NAME) usually live here?
A07

Did (NAME) stay here last night?
A08

PLEASE TICK THE ELIGIBLE WOMEN (15-49 YEARS)

HOUSEHOLD CHARACTERISTICS
B01

How many rooms in the house are used for sleeping?
B02

Does your family have a below poverty line (BPL) card?
B03

What is the primary source of income of the household?
B04

What is the main construction of the house?
B05

What is the main source of drinking water for members of your household?
B06

What kind of toilet facilities does your household have?
B07

What type of fuel does your household mainly use for cooking?
B08

Does your household have

B08_1

MATTRESS
B08_2

PRESSURE COOKER
B08_3

CASSEROLE/THERMOS
B08_4

CHAIR
B08_5

COT/BED
B08_6

TABLE
B08_7

ALMIRAH/DRESSING TABLE
B08_8

ELECTRIC FAN
B08_9

RADIO/TRANSISTOR
B08_10

COLOUR TELEVISION
B08_11

VCR/VCD/DVD PLAYER
B08_12

SEWING MACHINE
B08_13

MOBILE TELEPHONE
B08_14

ANY OTHER TELEPHONE
B08_15

COMPUTER/LAPTOP
B08_16

REFRIGERATOR
B08_17

WATCH/CLOCK
B08_18

BICYCLE
B08_19

MOTORCYCLE/SCOOTER
B08_20

ANIMAL-DRAWN CART
B08_21

CAR
B08_22

WATER PUMP
B08_23

THRESHER
B08_24

TRACTOR
B09

Does your household own any of the following animals

B09_1

COWS, BULLS, OR BUFFALOES
B09_2

HORSES, DONKEYS, OR MULES
B09_3

GOATS
B09_4

SHEEP
B09_5

CHICKENS OR DUCKS
B10

Does your household have electricity?
RESPONDENT CHARACTERISTICS
C01

What is your religion?

C02

What is your caste/category?
C03

IF THE CASTE IS A SCHEDULED CASTE, SCHEDULED TRIBE, OTHER BACKWARD CASTE OR OTHER.
C04

Are you a native of this village?
C05

In what month and year were you born?
C06

How old were you at your last birthday?
C07

Have you ever attended school?
C08

What is the highest level of school you attended
C09

What is the highest grade/form/year you completed at that level?
C10

Are you currently married or living together with a man as if married?
C11

Have you ever been married or lived together with a man as if married?
C12

What is your marital status now: are you widowed, divorced or separated?
C13

In what month and year did you first marry or start living with a man as if married?
C14

How old were you when you started living with your first husband/partner?
C15

When was the last time you had sexual intercourse?
C16

Are you currently pregnant?
C17

Is this your first pregnancy?
C18

Have you ever given birth to a boy or girl who was born alive but later died?
C19

TOTAL CHILDREN BORN AND PREGNANCY LOSSES
C20

TOTAL NUMBER OF LIVING CHILDREN AS OF NOW
C21

What is the (NAME) of your youngest child?
C22

When was your youngest child/(NAME) born?
FAMILY PLANNING
D01

Female Sterilization: Women can have an operation to avoid having any more children.
D02

Male Sterilization: Men can have an operation to avoid having any more children.
D03

Pill: Women can take a pill every day or every week to avoid becoming pregnant
D04

IUD or Loop or Copper T: Women can have a loop or coil placed inside them by a doctor or a nurse.
D05

Injectables: Women can have an injection by a health provider that stops them from becoming pregnant for one or more months.
D06

Condom or Nirodh: Men can put a rubber sheath on their penis before sexual intercourse.
D07

Female condom: Women can place a sheath in their vagina before sexual intercourse
D08

Rhythm method: Every month that a woman is sexually active she can avoid pregnancy by not having sexual intercourse on the days of the month she is most likely to get pregnant
D09

Withdrawal: Men can be careful and pull out before climax
D10

Emergency contraception: Women can take pills up to three days after unprotected sexual intercourse to avoid becoming pregnant.
D11

Lactational amenorrhea: A woman can avoid pregnancy if she is fully breastfeeding, her baby is less than 6 months old, and her period has not returned since the birth
D12

Do you know about birth spacing?
D13

Do you think there are any benefits of birth spacing?
D14

What are the benefits of birth spacing?
D15

Have you/your husband ever used any method to delay or avoid getting pregnant?
D16

Are you/ your husband currently doing something or using any method to delay or avoid getting pregnant?
D17

Which method are you/ your husband using?
D18

Since what month and year have you been using [MODERN METHOD] without stopping?
D19

When did you first start using [MODERN METHOD]?
D20

From where did you get this modern method of contraception?
D21

Were you using any method before? Or just before [CURRENT METHOD]?
D22

Which method were you using before? Or immediately before [CURRENT METHOD]?
D23

Just to ask once again, have you ever heard about “Injectables” method of family planning?
D24

Just to make sure, have you ever used “injectables” method of family planning?

D25

Have you heard of “DMPA Injection”?
D26

From where did you get to know about DMPA Injection?
D27

Do you know the frequency of taking DMPA injection?
D28

If yes, can you please tell us the frequency?
D29

Are there any advantages of using DMPA?
D30

If yes, can you name some of those advantages?
D31

Are there any side-effects of using DMPA?
D32

If yes, can you name some of those side-effects?

D33

Would you consider using “DMPA” in the future?
D34

If No, why not?
D35

Check IF Currently pregnant?
D36

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?
D37

Did you want to have a baby later on or did you not want any (more) children?
D38

Check IF Currently using “Female sterilization” or “male sterilization”?
D39

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?
D40

How long would you like to wait before the birth of (a/another) child?
D41

Check IF Currently using a contraceptive method?
D42

Do you think you are physically able to get pregnant at this time?
D43

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?
D44

How long would you like to wait before the birth of (a/another) child?
D45

Why do you think you are not physically able to get pregnant?
D46

When did your last menstrual period start?
D47

When you got pregnant with your youngest child, did you want to get pregnant at that time?
D48

Did you want to have a baby later on or did you not want any (more) children?
D49

How much longer did you want to wait?
D50

Has your menstrual period returned since the birth of your youngest child?
INTERACTIONS WITH FRONTLINE WORKERS AND PUBLIC PROVIDERS
E01

Did an AWW/ ASHA/ ANM/ Public Provider (doctor, nurse) ever discuss with you or your husband about the possibility of using methods to delay the next child or stop having children?
E02

Who all discussed with you?
E03

Which birth control methods were discussed during any of the conversations with an ASHA/?
E04

In the last 3 months, how many times have you or your husband met with an ASHA/ to discuss about the possibility of using methods to delay the next child or stop having children?
E05

Did an ASHA/ ever discuss with you or your husband about any of the injectables?
E06

Did an ASHA/ ever discuss with you or your husband about DMPA Injection?
E07

Did an ASHA/ ever discuss with you or your husband about the advantages of using DMPA?
E08

Did an ASHA/ ever discuss with you or your husband about the side-effects/danger signs of using DMPA?
E09

Did an ASHA / ever discuss with you or your husband about the frequency of taking DMPA?
E10

Which birth control methods were discussed during any of the conversations with an ANM?
E11

In the last 3 months, how many times have you or your husband met with an ANM to discuss about the possibility of using methods to delay the next child or stop having children?

E12

Did an ANM ever discuss with you or your husband about any of the injectables?
E13

Did an ANM ever discuss with you or your husband about DMPA Injection?

E14

Did an ANM ever discuss with you or your husband about the advantages of using DMPA?
E15

Did an ANM ever discuss with you or your husband about the side-effects/danger signs of using DMPA?
E16

Did an ANM ever discuss with you or your husband about the frequency of taking DMPA?
E17

Which birth control methods were discussed during any of the conversations with any of the public providers (doctor/nurse)?
E18

In the last 3 months, how many times have you or your husband met with any public provider (doctor/nurse) to discuss about the possibility of using methods to delay the next child or stop having children?
E19

Did any public provider (doctor/nurse) ever discuss with you or your husband about any of the injectables?
E20

Did any public provider (doctor/nurse) ever discuss with you or your husband about DMPA Injection?
E21

Did any public provider (doctor/nurse) ever discuss with you or your husband about the advantages of using DMPA?
E22

Did any public provider (doctor/nurse) ever discuss with you or your husband about the side-effects/danger signs of using DMPA?
E23

Did any public provider (doctor/nurse) ever discuss with you or your husband about the frequency of taking DMPA?
SATISFACTION
F01

Now, I would like to ask you about your satisfaction with the ASHAs/ANMs/ /Public Providers with regards to the family planning counselling or services provided by them.

F01A

ASHA

F01A_1

Being knowledgeable about methods of family planning?
F01A_2

Being able to counsel on family planning?
F01A_3

Being able to maintain privacy during counselling (no one else was present in the room during the counselling)
F01A_4

Being knowledgeable about injectables?

F01A_5

Being knowledgeable about DMPA Injection and its source of availability?
F01A_6

Being responsive to your needs of family planning?
F01A_7

Time availability to attend to you?
F01B

ANM

F01B_1

Being knowledgeable about methods of family planning?
F01B_2

Being able to counsel on family planning?
F01B_3

Being able to maintain privacy during counselling (no one else was present in the room during the counselling)
F01B_4

Being knowledgeable about injectables?

F01B_5

Being knowledgeable about DMPA Injection and its source of availability?
F01B_6

Being responsive to your needs of family planning?
F01B_7

Time availability to attend to you?
F01C

PUBLIC PROVIDER

F01C_1

Being knowledgeable about methods of family planning?
F01C_2

Being able to counsel on family planning?
F01C_3

Being able to maintain privacy during counselling (no one else was present in the room during the counselling)
F01C_4

Being knowledgeable about injectables?

F01C_5

Being knowledgeable about DMPA Injection and its source of availability?
F01C_6

Being responsive to your needs of family planning?
F01C_7

Time availability to attend to you?