03 mis woman's qre 11 dec 2012.xls

MALARIA INDICATOR SURVEY
MODEL WOMAN'S QUESTIONNAIRE
IDENTIFICATION (1)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . INTERVIEWER VISITS
LANGUAGE OF QUESTIONNAIRE, LANGUAGE OF INTERVIEW, NATIVELANGUAGE OF RESPONDENT, AND WHETHER TRANSLATOR WAS USED This section should be adapted to country-specific survey design.
SECTION 1. RESPONDENT'S BACKGROUND
Hello. My name is _______________________________________. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over (NAME OF COUNTRY). The information we collect will help the government to plan health services. Your household was selected for the survey. The questions usually take about 10-20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time.
In case you need more information about the survey, you may contact the person listed on the card that has already been given to your household. Do you have any questions? May I begin the interview now? RESPONDENT DOES NOT AGREE TO BE INTERVIEWED HOUR . . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . . COMPARE AND CORRECT 102 AND/OR 103 IF INCONSISTENT.
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 What is the highest level of school you attended: primary, secondary, . . . . . . . . . . . . . . . . . . . . . . . 1 or higher? (1)
. . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . . . . . . . . . . . . . . . . . . . What is the highest (grade/form/year) you completed at that level? (1)
IF COMPLETED LESS THAN 1 YEAR AT THAT LEVEL,RECORD '00'.
Now I would like you to read this sentence to me.
SHOW CARD TO RESPONDENT. (2)
SENTENCE . . . . . . . . . . . . . . . . . . . . . 2 IF RESPONDENT CANNOT READ WHOLE SENTENCE, PROBE: Can you read any part of the sentence to me? COUNTRY-SPECIFIC QUESTION ON RELIGION, IF APPROPRIATE.
COUNTRY-SPECIFIC QUESTION ON ETHNICITY, IF APPROPRIATE.
In the past 6 months, have you seen or heard any messages about YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 . . . . . . . . . . . . . . . . . . . . . B (1) Revise according to the local education system.
(2) Each card should have four simple sentences appropriate to the country (e.g., "Parents love their children",
"Farming is hard work", "The child is reading a book", "Children work hard at school"). Cards should be prepared for every language in which respondents are likely to be literate.
SECTION 2. REPRODUCTION
Now I would like to ask about all the births you have had during your YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Do you have any sons or daughters to whom you have given birth who YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Do you have any sons or daughters to whom you have given birth who YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 How many sons are alive but do not live with you? And how many daughters are alive but do not live with you? Have you ever given birth to a boy or girl who was born alive but later died? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Any baby who cried or showed signs of life but did . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 SUM ANSWERS TO 203, 205, 207, AND ENTER TOTAL.
NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Just to make sure that I have this right: You have had in TOTAL _____ births during your life. Is that correct? NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00 Now I would like to record the names of all your births in the last 6 years, whether still alive or not, starting with the most
recent one you had.
RECORD NAMES OF ALL THE BIRTHS IN THE LAST 6 YEARS IN 212. RECORD TWINS AND TRIPLETSON SEPARATE ROWS.
Have you had any live births since the birth of (NAME OF MOST YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 RECENT BIRTH)? IF YES, RECORD BIRTH(S) IN TABLE.
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 COMPARE 210 WITH THE NUMBER OF BIRTHS IN HISTORY ABOVE AND MARK: ENTER THE NUMBER OF BIRTHS IN 2008 OR LATER.
NONE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 0 YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 UNSURE . . . . . . . . . . . . . . . . . . . . . . . . . MONTHS . . . . . . . . . . . . . . . . . . . IN 2008 (1)
IN 2008 (1)
(1) Year of fieldwork is assumed to be 2013. For fieldwork beginning in 2014 or 2015, the year should be 2009
SECTION 3. PREGNANCY AND INTERMITTENT PREVENTATIVE TREATMENT
CHECK 215: ENTER IN THE TABLE THE NAME AND SURVIVAL STATUS OF THE MOST RECENT BIRTH.
Now I would like to ask some questions about your most recent pregnancy that resulted in a live birth.
When you were pregnant with (NAME), did you see anyone for YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Whom did you see? (1)
DOCTOR . . . . . . . . . . . . . . . . . . . . . . A NURSE/MIDWIFE . . . . . . . . . . . . . . . . BAUXILIARY MIDWIFE PROBE TO IDENTIFY EACH TYPEOF PERSON AND RECORD ALL WORKER . . . . . . . . . . . . . . . . . . . . E During this pregnancy, did you take any drugs to keep you from YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 DON'T KNOW . . . . . . . . . . . . . . . . . . . . 8 SP/FANSIDAR . . . . . . . . . . . . . . . . . . . . ACHLOROQUINE IF TYPE OF DRUG IS NOT DETERMINED, SHOW TYPICAL DON'T KNOW . . . . . . . . . . . . . . . . . . . . Z How many times did you take (SP/Fansidar) during this pregnancy? TIMES . . . . . . . . . . . . . . . . . . . . Did you get the (SP/Fansidar) during any antenatal care visit, during another visit to a health facility or from another source? OTHER SOURCE . . . . . . . . . . . . . . . . . . 6 BORN IN 2008 (2) OR LATER
(1) Coding categories to be developed locally and revised based on the pretest; however, the broad
(2) Year of fieldwork is assumed to be 2013. For fieldwork beginning in 2014 or 2015, the year should be
SECTION 4. FEVER IN CHILDREN
CHECK 215: ENTER IN THE TABLE THE BIRTH HISTORY NUMBER, NAME, AND SURVIVAL STATUS OF EACH BIRTH
IN 2008 (1) OR LATER. ASK THE QUESTIONS ABOUT ALL OF THESE BIRTHS. BEGIN WITH THE LAST BIRTH.
(IF THERE ARE MORE THAN 3 BIRTHS, USE ADDITIONAL QUESTIONNAIRES).
Now I would like to ask some questions about the health of your children born since January 2008. (We will talk about each separately.) treatment? (2)
Where did you first seek advice or treatment? What drugs did (NAME) take? (3)
QUESTIONNAIRE; OR,IF NO MORE BIRTHS,GO TO 426.
HOUR . . . . . . . . . . . . . . . . . . . . . . . . MINUTES . . . . . . . . . . . . . . . . . . . . . . (1) Year of fieldwork is assumed to be 2012. For fieldwork beginning in 2013 or 2014, the year should be 2008
(2) Coding categories to be developed locally and revised based on the pretest; however, the broad categories
(3) Coding categories to be developed locally and revised based on the pretest. All antimalarials commonly used
in the country should be included in the response categories. Common brand names of drugs, such as Bayer,Tylenol, or Paracetamol, should be added to the response categories for aspirin, acetaminophen, or ibuprofen as appropriate.
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW.
SUPERVISOR'S OBSERVATIONS
EDITOR'S OBSERVATIONS

Source: http://malariasurveys.org/toolkitfiles/03%20Woman's%20Questionnaire.pdf