APPENDIX E SURVEY QUESTIONNAIRES
APPENDIX E
SURVEY QUESTIONNAIRES
SDKI91
]
SDKI91-RT
1991 I N D O N E S I A D~IMOGRAPHIC A N D H E A L T H S U R V E Y
HOUSEHOLD SCHEDULE
Confidential
IDENTIFICATION
i. P R O V I N C E
CODE
..........................................
2. R E G E N C Y / M U N I C I P A L I T Y
*) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. S U B - D I S T R I C T
4. V I L I A G E
5. A R E A
. . . . . . . . . . . . . . . . . . . U R B A N - 1 ..... R U R A L -
D
D
2 **)
6. L A R G E C I T Y / S M A L L C I T Y / T O W N / C O U N T R Y S I D E .............
(Large city=l, S m a l l city=2, Town=3, C o u n t r y s i d e = 4 )
7. E N U M E R A T I O N A R E A N U M B E R
8. S P 9 0 S A M P L E C O D E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. I D H S 9 1 S A M P L E C O D E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
L0. H O U S E H O L D
NUMBER ................................................
Ll. N A M E O F H O U S E H O L D
HEAD
INTERVIEWER
1
VISITS
2
FINAL VISIT
MONTH
DATE
.................
INTERVIEWER'S
N A M E ....
S
INTERV.
FINAL RESULT
AL ERII
DATE
OF VISITS
TIME
***) R E S U L T CODES:
1 COMPLETED
2 H O U S E H O L D P R E S E N T BUT N O C O M P E T E N T RESP. A T H O M E
3 HOUSEHOLD ABSENT
4 POSTPONED
5 REFUSED
6 D W E L L I N G V A C A N T O R A D D R E S S t40T A D W E L L I N G
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER
T O T A L IN
HOUSEHOLD
TOTAL
ELIGIBLE
WOMEN
DATE IFIEEDIOBYIoFIEOIOBYI YEOBY
*)
**)
***)
--
YE~.R
R E S U L T ***) ...........
N E X T VISIT:
~
Cross out category not used
Circle selected category
Choose suitable result
195
I KEYEDBY
HOUSEHOLD
NO¢4 ~e UOULd h k e soe~e i n f o r m a t i o n abo~t t h e p e o p l e teho u s u a l l y
NO,
USUAL RESIDENTS
hve
In your" h o u s e h o l d ,
1 I'oe
I
TO HEAD OF
m HOUSEHOLD
EDUCAT[OI4
FOR ALL PERSONS AGED 5 AND ABOVE
--|
P l e a s e g { v e me t h e names
o f t h e persons hho u s u a l l y
t i r e i n your h o u s e h o l d ,
s t a r t i n g w i t h t h e heed o f
the household,
(1)
I I
What IS
the
relationship of
i (HARE) 1,o
i t h e head
; of the
, househotd?'
(2)
Is (NM4E)
m a l e or"
female?
(4)
(5)
I
I
H
IT1
Has
What i s t h e
(NANA)
highest
ever
' Level o f
been t o
school
schooL?
(NANE)
a t t ended~**
FO~ALL
PERSO~4SAGED
LESS THAN
25 YEARS
[s (NAME)
(3)
I
HOW o l d
IS
(MANE)?
,2
f
(6)
I
YEARS
IT1
•11at ~S t h e
highest
grade
=ot~pl e t ed? t t
(7)
st{It in
schooL?
.EVEL
YES
I
YES
NO
GRADE
E
(8)
NO
1
2
t
2
1
2
t
2
2
Z
o,
rl-l.,
F
Z
Z
2
2
2
2
[
COOES FOR COLUMN ( 3 ) :
RELATIO~SH[P TO HEAD OF HOUSEHOLD:
01= HEAD OF HOUSEHOLD
02= ~IFE OR HUSBAND
03 = CHILD
04= SON OR DAUGHTER-IN-LAW
05= GRANDCHILD
06 = PARENT
07= PARENT-]N-LA~
08= BROTHER OR SISTER
09 = OTHER RELATIVE
10= ADOPTED/FOSIER CHILO
11 = NOT RELATED
98= OK
196
t
E
1
2
I
Z
= ' ) COOES FOR COLLmqt~( 7 ) :
LEVEL OF EDUCATiOn:
1= PRlidARY
2 = JUNIOR HIGH
3= SENIOR HIGH
4= ACADENY/UNI VERS[ Iy
8 = DK
GRADE:
0 = LESS THAN 1 YEAR CQMPLE1ED
8= DK
SCHEDULE
FOSTERING***
NARXTAL
$1AtU$
ELIGIBILITY
IF AGED LESS THA~ 15 YEARS
IF ALIVE
Is (MANE)'=
p~turat
it~ther alive9
19)
,
:YES
NO
Does (NANE)'s
natural mother
Live in this
ho~mehotd?
I
O
I I
8
IF YES;
k~lat i s h e r p,e~e?
IF YES:
I~hlt tS b i b r~l~t~
RECORD NOTHER'S
L]NE NUMBER
RECORD FATHER=S
LINE NUMBER
110)
MO
AGED 10
AND ABOVE
CIRCLE LINE
~LM~E~ OE A~L
EVER'MARRIED
tdO#EN AGED
15-49
Has (NAME)
ever be~
married?
112)
(11)
YES
DK
1
IF ALIVE
Is IN~E)'=
,
natural
Does (I~AJ4E)' s
f a t h e r a l i v e ? r~lmttJra=l f a t h e r
live tn thtli
hOU~eho[dT
OK
(16)
113)
YES
NO
01
02
I
1
8
1
8
1
8
1
8
1
8
,
E
~-]
03
O~
1
o
J-~
OS
O6
07
1
1
8
1
8
1
8
1
8i
1
8
1
E
1
O
1
E
"*')
Oa
10
I
'
°i
1
o
o
J-~
J~
1
11
1
12
1
13
1
16
1
15
Th{£ ~ s t i ~
refers to the biological parents of the child.
Record *00 ~ t f p a r e n t n o t m e e t ~ r o f t h e h o u s e h o l d .
r--7
JJ
TICK HERE IF CONTINUATI~ SHEET USED
~t
TOTAL ML~4BEROF ELIBIBLE VJ(]MEN
171
t o T~l~ke $~re I have ~ c o m p l e t e l l $ t i r ~ ] :
1) A r e t h e r e any p e r s o n s such as sma~l c h ~ I d r e n o r
i n f a n t s thet ~ h a v e n o t l i s t e d ?
2) A r e t h e r e any o t h e r p e o p l e i~ho may n o t be memL~rs o f yc~Jr f a m i l y ,
like servants, friend,
l o d g e r s , t:=Jt who u s ~ l l y
l i v e here~
3) A r e t h e r e any o t h e r g ~ i t B or V i s i t o r s who h a v e been
t e c p o r a r t [ y s t a y i n g M i t h you f o r t h e p a s t 6 months o r more?
4) Are t h e r e any persons who u s u a l l y
f o r l e s s t h a n 6 month=?
l i v e h e r e kho h a v e been away f o r
5) A r e t h e r e any p e r s o n s ~e h a v e l i s t e d
p o s t 6 months?
Who have been a~ay f o r t h e
,Es D - . E ~ , .
,,OH ,, EA,~E
YES ER.E,,E, E" "'"LE
'E$ ER'E'TER
" '''LE
'o I--7
'o8
NO.
QUESTIONS AND FILTERS
15
U h e t t s t h e souPce o f ~ a t e r y o u r h o ~ e h o l d
f o r h a n d ~ a s h l n g and d t s h N a s h i n g ?
I
16 I
I
17
18
19
20
Hc~ t o n g does t t
and c o ~ b a c k ?
t a k e t o go t h e r e ,
22
~es
get water,
Does y o u r h o u s e h o l d g e t d r i n k i n g
. f r o m t h i s same ~ o u r c e ?
uater
~8t
is the source of drinking water
f o r members o f y o u r h o u s e h o l d ?
~dhat k i n d o f
toilet
facitity
does y ~ u r h o u s e h o t d have?
IdELL . . . . . . . . . . . . . . . . . . . . . . . . . . .
SPRING . . . . . . . . . . . . . . . . . . . . . . . . .
RIVER . . . . . . . . . . . . . . . . . . . . . . . . . .
RAINWATER . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
05
MINUTES . . . . . . . . . . . . . . . . .
06
07
08
09
I
[
~qAIg MATERIAL OF THE FLOOR.
198
t
1-->19
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Z
PIPED INTO RESIDENCE . . . . . . . . . . .
PIPED INTO YARD OR PLOT . . . . . . . .
PUBLIC TAP . . . . . . . . . . . . . . . . . . . . .
p~p ...........................
WELL . . . . . . . . . . . . . . . . . . . . . . . . . . .
SPRING . . . . . . . . . . . . . . . . . . . . . . . . .
RIVER . . . . . . . . . . . . . . . . . . . . . . . . . .
RA I M~/ATER. . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
01
02
03
04
OS
PRIVATE, W. SEPTXE TANK . . . . . . . . .
PRIVATE, NO SEPTIC TANK . . . . . . . . .
$HARED/PU8L]C . . . . . . . . . . . . . . . . . . .
01HER
(SPECIFY)
1
2
3
BICYCLE/BOAT . . . . . . . . . . . . . . .
I~TOR VEHICLE . . . . . . . . . . . . . .
TILE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONCRETE/BRICK . . . . . . . . . . . . . . . . . .
............................
BANBO0 . . . . . . . . . . . . . . . . . . . . . . . . . .
DIRT/EARTH . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
(RECORO 06SERVATTO~.)
~
996
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ELECTRICITY . . . . . . . . . . . . . . . .
RADIO OR CASSETTE . . . . . . . . . .
TELEVISIO~ . . . . . . . . . . . . . . . . .
STOVE . . . . . . . . . . . . . . . . . . . . . .
O ~ s a n y member o f y o u r h o u s e h o l d h a v e o r h a v e
access to:
A bicycLe/boat?
A mtor vehicle?
I
01"-'-- I
02~>17
03
Does y o u r house h a v e :
Stove?
,o
PIPED INTO RESIDENCE . . . . . . . . . . .
P[PED INTO YARD OR PLOT . . . . . . . .
PUBLIC TAP . . . . . . . . . . . . . . . . . . . . .
PREN]SES . . . . . . . . . . . . . . . . . . .
ELectricity?
A radio or cassette?
A television?
A gas, kerosene or electric
21
I
COOING CATEGC~IES
06
07
08
09
4
YES
NO
1
1
1
1
2
2
Z
2
YES
1
1
NO I
2
2
1
2
3
6
E
6
I
t
i SDKI91
i
SDKI91-WK
1991 I N D O N E S I A D ~ 0 G R A P H I C
AND HEALTH SURVEy
INDIVIDUAL WOMAN'S QUESTIONNAIRE
Confidential
IDE~TIFICATION
1. P R O V I N C E
CODE
.................
2. R E G E N C y / M U N I C I P A L I T Y
*)...
3. S U B - D I S T R I C T
4. V I L L A G E
5.
. .UP/~AN
AREA
- 1 ..... R U R A L -
D
[]
2 **)
6. L A R G E C I T Y / S M A L L C I T Y / T O W N / C O U N T R Y S I D E .............
(Large city=l, S m a l l city=2, T o w n = 3 , C o u n t r y s i d e = 4 )
7. E~qUMERATION A R E A N U M B E R
8.
V--r--7--q
SP90 SAMPLE CODE ................................................
9. I D H S 9 1 S A M P L E C O D E
~ER...IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I iiiiiiiiiiii
10 .oosENo~
ii. NA24E O F H O U S ~ O I / )
H~
12. L I N E NI24BER O F W O M A N F R O M H O U S E N O L D S C H E D U L E . . . . . . . . . . . . . . . . . . . . . . .
i
13. N A M E O F W O M A N
INTERVIEWER
VISITS
2
DATE
FINAL VISIT
.................
INTERVIEWER'S
INTERV.
N A M E ....
I ~ U L T ***) . . . . . . . . . . .
FINAL RESULT
I
INEXTVISIT:
DATE
TOTAL NUMBER
OF VISITS
TIME
***) R E S U L T CODES:
1 COMPI~TED
2 NOT AT HONE
3 POSTPONED
NAME
DATE
*)
**)
***)
I
4 REFUSED
5 PARTLY COMPLETED
6 OTHER
l°
Cross out category not used
Circle selected category
Choose suitable result
199
I
I
[]
200
I SECTI~ I .
NO. I
RESFGMDENT'SBACKGROUNDI
I
~JESTIO~S AND FILTERS
I S~IP
TO
COOING CATEGORIES
i
F i r s t % UOuLd l i k e to ask io~equestion= about you.
For mos¢ of the tir~e u n t i l you v~re 12 years old, dLd
you l i v e i n a vftLage, in n t ~ .
or in m c i t y ?
102
CITY . . . . . . . . . .
• TOiJN. . . . . . . . . . . . . . . . . . . . . . . . . . . .
VILLAGE . . . . . . .
.1
E .
3
103 II In i~'~atmor~thandyear w~re you born?
IF l~qTHNOT IN i4ESTERNCALENDAR,W lTENAME:
I
.
.
.
.
.
GO~PARE AND CO~RECT 10] AND/(Xq 104 [F INCOI4SISTENT.
IF AGE LESS THAN 15 (~ 5 ~ , END iNTERVIEW.
104A I
Are y~J ~ow meJrrted, uidowed, or dIvorce~?
14ARR%ED. . . . . . . . . . . . . . . . . . . . . . . . .
O%VOICED. . . . . . . . . . . . . . . . . . . . . . . .
I
106 I
I
I
107 I
I
108 I
_ _ 0
1 I
2
I
.........................
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->109
Q/hat is the highest Level of school you attended:
primary, j u n i o r high, senior high, acad¢t~, or
university?
PRIMARy. . . . . . . . . . . . . . . . . . . . . . . . .
JUN%0~ HIGH SCHOOL. . . . . . . . . . . . . .
SENIOR HIGH SCHOOL. . . . . . . . . . . . . .
ACADEMY/UNIVERSITY. . . . . . . . . . . . . .
1
2
3
4
t h a t is the hLghest (GRADE, FGRM, YEAR) you completed
I t t h l t level?
GRJ~OE. . . . . . . . . . . . . . . . . . . . . . . . .
CHECR 106:
E~
D
JUXI{~ HiGH
PRIMARY
OR HIGHER
i
V
>110
I
109
110
111
]
cart you reed and understand a Letter or r-~wspeper
e a i i [ y , = l t h d i f f i c u l t y , or not ot a(L?
DO you~suaLty read a newipaper or musgazLr~ at Least
orice a ~eek?
Do yov.r USL~lLy [ i S t ~
tO the radio every d~ay?
11Z
Do
l you
e a -L~s~t
-ak ? sty watch
t
c t e l e~v i s i oe n . t
113
~lhat r e l i g i o n are yo~J?
EASILY . . . . . . . . . . . . . . . . . . . . . . . . . .
WITH DIFFICULTY. . . . . . . . . . . . . . . . .
MOT AT ALL . . . . . . . . . . . . . . . . . . . . . .
I
I
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
I
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 I
I
..............................
2
I
YES.N.O
.........................................................
21
i
MUSLIM. . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. . . . . .
PROTESTANT/CHRISTIAN
CATKOLIC. . . . . . . . . . . . . . . . . . . . . . . .
HINDU. . . . . . . . . . . . . . . . . . . . . . . . . . .
BUDDHIST. . . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPEC%FY)
2I
]
4
5
6
I
I
I
201
I
E I
3~>111
I
NO
I
SECT]ON 2,
REPROOUCT]Ce4I
QUESTIONS AND FILTERS
~
o i N
' ~ l~ rLE~~ ourSe •t ° hs H- e- t y~
a e ethe~
d l e o th~ rYt h~ h - -
~0,j Ho,~.oy.... i ..... ~hyoo,
I
SKIP
I TO
CODING CATEGORIES
............................. I
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->206
WO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->20~
I s°NBAT- ............... ~l
And hOW many d a u g h t e r s L i v e w i t h you?
DAUGHTERS AT HOI4E. . . . . . . . . .
IF
HONE ENTER ' O 0 ' ,
given birth
who a r e a l i v e b v t do n o t l i v e w i t h you7
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
206 J
I
207
And hofl m~ny d a u g h t e r s are a l i v e ~ J t ~
you "~
COt t i r e
2-->206
with
DAUGHTERSELSEUNERE. . . . . . . .
[F NONE ENTER *00 I .
Have
born
baby
only
you e v e r g i v e n b i r t h t o a boy o r a g i r t who was
8 l i v e b u t l a t e r d i e d ? IF NO. PROBE: Any ( o t h e r )
~ho c r i e d o r sho~ad any s i g n o f ~ i f e b u t
s u r v i v e d a few hours o r days?
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 I
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->208
I
I
] n a l l , hOW m~ny boys h a v e d i e d ?
And how many 9 i r ~ s h a v e d i e d ?
[F NONE ENTER ' 0 0 ~.
SUN ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
TOTAL . . . . . . . . . . . . . . . . . . . . . .
[F NONE ENTER JOB I .
2O9
CHECK 208:
J u s t t o rPake sure t h a t I have t h i s
your L i f e . I s t h a t c o r r e c t ~
IES ~
NO i
r~gh~: you have had i n TOTAL -
l
-
Live births
(~Jrtr~J
PROBE AWD
• CDeREC1 201-209 AS ~ECESSARY
/
V
210
CHECK 208:
ONE OR HORE [ ~
hO BIRTHS ~ ]
>225
I
202
211
NC~ I Would Like t o t a l k t o you about a l l
f i r s t on~ you had.
(RECORD NA~4ES OF ALL THE BIRTHS iN 212,
212
213
Jhat ne~e was
~iven t o y o u r
(flrst,r~xt)
~aby~
whether s t i l l
a l i v e or not, s t a r t i n g
with the
RECORDTWINS AND TRIPLETS ON SEPARATE LINES).
21&
215
216
[s
(NAME)
a boy o r
a 9irt?
I n what r ~ n t h
IsncI y e a r Was
(NAME) born?
IS (N/d4E) HOW o l d WaS
StiLL
; ( N ~ E ) at
alive?
: his/her last
b l r t hday?
RECORD
SINGLE
OR
WtJLTIPLE
BIRTH
STATUS
o!I
o f yc*Jr b i r t h s j
21}'
IF ALIVE:
PROBE:
~11at i s h i s /
h e r bi r t h d a y~
OR: I n wt~at
seoson?
21B
IF ALIVE:
220
IF DEAD:
I s (NAME)
[LvIn~
w i t h yc4J?
HOW o t d was h e / s h e
when he/she dlC'~d?
IF -1 y R . - PR~E:
HOW rlzany IPO~ths
o l d was (MANE)?
RECORD AGE
IN COMPLETED
YEARS
SING..,1
BOY,..1
MX~NTH,. ~
YES'''1
MOLT...2
GIRL..2
TEAR..*
NO....2
J
(NAME)
RECORD DAYS IF LESS
THAN I RO¢~T½,NONTHS
[F LESS THAN ll~K~
YEARS, ~ YEARS.
IF LESS THAW I~qE
DAY, W~ITE *00'
OAYS, . . , 1
AGEyEARsIN
YES. . . . . . .
MONTHS,.2
~ l
NO. . . . . . . . 2
(GO TO NEXT
BIRTH)"
NO. . . . . . . . 2
(GO TO NEXT
I,~,ONTHS..2
BIRTH)<
YEARS...3
v
22O
1
YEARS,. ,3
(NAME)
2ZO
%
M,
ULT...2
GIRL..E
YEAR...
NO....2
I
( NJzi'4E)
;
YEARS
F ~
v
ZEO
j
~
%
(NAME)
220
BOY,, ,~
MONTH.,
YES...)
M~JLT...2 , GIRL..2
SING,.,1
YEAR...
NO....2
I
(NAME)
v
AGE IN
YEARS
III
YES. . . . . . .
]
1
DAYS....
1
NO. . . . . . . . 2
(GO 10 NEXT
BIRTH)<
k~O~TRS.. 2
NO. . . . . . . . 2
(GO TO NEXT
BIRTH)(
HOWlHS. ,2
YEARS...3
22C
(NAME)
220
SING,, ,1
BOY...1
MONTH..
YES,..1
MULT...2
G]RL..2
YEAR...
NO. , . ,2
I
(NAME)
v
220
203
AGE iN
YEARS
YEARS...3
212
213
~ B t rt~T~ W&s
gJvc~rl tO your
(first,next)
baby~
214
215
216
217
IF ALIVE:
E18
IF ALIVE:
220
IF DEAD:
Is
INANE)
a boy o r
8 girl ~
I n ~ a t J~C~th
a r d year was
(NARE) born?
IS INANE)
stilt
alive?
HOW o l d was
(NAME) a t
his/her fast
birthday?
I s (NANE)
living
~ i t h you ?
How o l d was h e / s h e
~hen h e / s h e d i e d ?
RECORD
SINGLE
OR
NULT]PLE
BERTH
PROBE:
g h a t IS h i s /
her b i r t h d a y ?
OR: [n wh~t
season?
IF " 1 Y R , " , PROBE:
HO~ many months
o l d wes (NAME)?
RECORD AGE
IN CO)4PLETED
YEARS
REC(~D DAYS IF LESS
THAN 1MONTH,HOMTB$
IF LESS THAN Tl~O
YEARS, OR YEARS.
IF LESS THAN O~E
DAY, ~P[TE DBO~
STATUS
8]
SING...1
BOY.,.1
HONTH.,
YES..,1
14ULT.,.2
GIRL,,2
YEAR..,
NO.,.,2
J
AGE [N
YEARS
22O
( NAJ4E)
[ ~
v
09•
SING,..1
BOY,.,1
NONZH..
YES...1
i
MULT..,2
G]RL,,2
YEAR.,.
NO....2
J
J
INANE)
v i
AGE IN
YEARS
~
ill
220
SZNG...1
BOY, . , 1
~TH..
NULT, . ,2
G]~L..2
YEAR* , .
]
I
(NAME)
~J
AGE IM
YEARS
SING, , . 1
BOy... 1
MONTH.. ~ 1 ~
YES.,.1
K4JLT...E
G[RL,.E
YEAR,.,
NO,,.,E
J
v
220
(NAI4E)
12J
YES...1
NO, , , .2
J
v
2CO
i
SING...1
BOY,. , I i V~NTH..J
V/JLT,,.2
G[RL..E i YEAR,..
I,
[NAME)
J
J
yES...1
NO.,.,2
J
SING...1
BOY...1
NONTH.. ~ [ ~
YES...1
~JLT . . .2
GIRL. ,2
YEAR. , ,
NO. , . ,2
DAYS''''1
V~NTHS..E
YES. . . . . . .
DAYS''''1
1,
YEARS,.,3
NO. . . . . . . . 2(GO TO NEXT
BIRTH)(
MONTHS,.2
YES. . . . . . .
DAYS'''*1
1-
YEARS...3
NO. . . . . . . . 2
(GO TO NEXT
B]RTB),-
MOflTBS,.2
YES. . . . . . .
BAYS..,,1
[ ~
AGE IN
YEARS
~
ill
AGE IN
YEARS
J
v
(NAME)
1,
NO. . . . . . . . 2,
(C'OTO NEXT
BIRTH)326
SK[P
NO.
OUEST[ONS AND FILLERS
~7
l TO
COOTNG CATEGORIES
l
Are you h a v i n g ~ny h e a l t h probLen~ i n u s i n g
(CURRENT METHOD)?
.............................
, t
2-->328A
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
328
~ h a t t s t h e ma+n h e a r t h probtam~
Are y o ~ h a v l n g a n y o t h e r p r o b [ ~
(CURRENT METHOD)?
328/~
328B
~EIGHT GAIN . . . . . . . . . . . . . . . . . . . .
~EIGHT LOSS. . . . . . . . . . . . . . . . . . . .
BLEEDZNG. . . . . . . . . . . . . . . . . . . . . . .
HVPERTENSIQ~. . . . . . . . . . . . . . . . . . .
HEADACHE. . . . . . . . . . . . . . . . . . . . . . .
NAUSEA. . . . . . . . . . . . . . . . . . . . . . . . .
A~ENORRHEA. . . . . . . . . . . . . . . . . . . . .
IgEAK/TIRED. . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
D~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I n u~ing
~Jhat I s t h e I1~1n p r o b [ ¢ ~
01
02
O~
04
05
06
O~
08
09
98
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2--~329
HUSBAND OIBAPPROVES. . . . . . . . . . . .
ACCESS/AVAILABILITY . . . . . . . . . . . .
COSTS TOO~LJCN. . . . . . . . . . . . . . . . .
INCONVENIENT TO USE . . . . . . . . . . . .
STERILIZED,
~ANT$ C½[LDREN. . . . . . . . . . . . . . . .
OTHER
(SPEC%FY)
OK. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
01
02
03
01.,
OS
06
98
CHECK 315 AND 321:
329
STERIL)ZED BEFORE JANUARY 1986
I
NEITHER
STERILIZED
[~
STERIL]ZED SINCE JANUARY 1966
I
~348
I~
>331
L
iii V
330
ENIER NETHCX) CODE FRC~4315 IN CURRENT MONTH IN COLI1 OF CALENDAR. THEN DETERMINE WHEN SHE
STARTED USING THIS METHOD THIS TIME. ENTER METHOD COOE IN EACH MONTH OF USE,
ILLUBTRATIVE QUESTIONS:
tCnen d i d you s t a r t u s i n g t h i s method c o n t i n u o u s l y ?
HOW Tong have you been u s i n g t h i s method contlnuo~sLy~
33~
would ~ik~ to a~k some ~est~on~ about all of the (other} periods in the fast few years
dIJring ~.hlCh you used a rc~thod t o avoid g e t t i n g p r e g n a n t .
USE CALENDAR TO PROBE FOR EARL]ER PERICOS OF USE AND NI~flUSE, STARTING W]TH HOST RECENT
USE, BACK TO JANUARY 1986.
USE NAJ4ES OF CHILDREN, DATES OF GIRTH, AND PERIOOS OF PREGNANCY AS REFERENCE POINTS.
IN EACH MONTH, ENTER CCOE FOR NETHCO OR -O- FOR NONUSE IN COLIJNN 1.
ENTER COORS FOR DISCONT]NUANON NEXT TO LAST VA)NTH OF USE.
[N COLUMN 2,
NLR45ER OF COOES ENTERED IN COLUMN 2 NJST BE THE SANE AS
THE NUI4BEROF INTERRUPTIONSOF CONTRACEPTIVE USE IN COLL~4N t
ASK UHy SHE STOPPED USING IRE METHO0. iF A PREGNANCY FOLLO~IED, ASK WHETHER SHE
9ECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHO0 OR DELIBERATELY STOPPED
TO GET PREGNANT.
ILLUSTRATIVE OUESTIONS:
COLL~IN 1:
-When was the Last t i e
you used a ¢nethod~ Which method vas t h a t ?
-When d i d you s t a r t u s i n g t h a t method~ HOW tong a f t e r the b i r t h o f (NANE)~
-HOW long d i d yc~ use the ~ t h o d then?
COLUI4N 2:
*Why d i d yC*J s t o p uSing the (METHI~)*P
- D i d you I~cc~e pregnant w h l ( e u s i n g (NETHO0), Or d i d you s t o p t o get pregnant~
o r s t o p f o r soq~ o t h e r reason?
IF DELIBERATELY STOPPED 10 BECC~4E PREGNANT, ASK:
-HOW fl~n¥ n x ~ t h $ d i d I t take you t o get pregnant a f t e r you stopped u s i n g (METHO0)?
AND ENTER - 0 - IN EACH SUCH MONTH IN COLUNM 1.
12
211
SKiP
.o. j
COUIN~, CA I EI~O~I ES
UUE~ILON~ AND f l l l L ~
I io
CHECK CALENDAR:
NO METHOD USED
[N MONTH OF JAN. 1986
METHOD USED IN NONTH OF JAN* 1986
V
[ see t h a t
333
you were usir~
~Jher~ d i d yc~J s t a r t
using
(NETHQD] i n J a n ,
(METH(~}) t h a t
1986.
tlt~ ~
MO~TH . . . . . . . . . . . . . . . . . . . . . .
YEAR . . . . . . . . . . . . . . . . . . . . . . .
[ ~ . J
>$38
k~l
( T H I S DATE SHOULD NOT PRECEDE THE DATE OF BIRTH
OF ANY CHILD BORN BEFORE JAN. 1986)
334
I see t h a t y o u were r ~ t u ~ l n g a n y r~ethod
of contraceptl¢~
I n J a n . 1986.
Did yc~ ever use
a r~*thod before thnt?
I|
!
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2--~3~d3
I
335
CHECK 215;
½KD BIRTH
BEFORE JAN. 1986
I YES.............................
D i d yOU u s e a m e t h o d b e t w e e n t h e b i r t h o f
(NAME OF LAST CHILD BOR~ BEFORE JAN. 1986)
a n d J a n . 1986?
336
337
NO B[RTH
BEFORE JAN. 1986
I
When d i d y o u s t o p u s i n g
p r i o r t o Jan. 1986?
the
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
' I
2-->3~
Last tllE~
I- ......................
YEAR
. . . . . . . . . . . . . . . . . . . . . . .
13
212
NO.
338
QUESTIOHS AND FILTERS
CO0)NG CATEGORIES
I
CURRENTLY
I
NETHO0
I
CURRENTLY USING PERIO01C A6STINENCE
METH~ITHDRAWAL'
OTHER TRADITIONAL
~v
CHECK 3 1 5 :
USINGNOT
CURRENTLYA
METXOD
I
~
USING A NOOERN [ ~
(SKIP TO 344)
SKIP
TO
>3!.~
I
V
339
340
DO you I n t e ~
t o use a ~ t h o d t o d e [ e y
pregnancy at any time in the future?
Whot i s t h e ~ l n
a method?
reas~
y~
®
not
o r ovoid
intend
to use
I
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1-->341
NO ..............................
2
DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
WANTS CHILDREN. . . . . . . . . . . . . . . . .
LACK OF KNtTALEDGE. . . . . . . . . . . . . .
PARTNER OPPOSED. . . . . . . . . . . . . . . .
'
I
>344
0182
03
04
05
06
07
COST TOO MUCH. . . . . . . . . . . . . . . . . .
SIDE EFFECTS . . . . . . . . . . . . . . . . . . .
HEALTH CO~¢CERNS. . . . . . . . . . . . . . . .
HARD TO GET METHODS. . . . . . . . . . . .
RELIGIO(d . . . . . . . . . . . . . . . . . . . . . . .
OPPOSED TO FAMILy P L A N N I N G , . , . , 0 9
FATALISTIC . . . . . . . . . . . . . . . . . . . . .
10
RELATIVES OPPOSED . . . . . . . . . . . . . .
11
INFREQUENT SEX . . . . . . . . . . . . . . . . .
12
DIFFICULT TO GET PREGNANT. . . . . . 13
NENO@AUSAL/HADHYSTERECTOMY.,..1&
INCONVENIENT. . . . . . . . . . . . . . . . . . .
13
NOT MARRIED. . . . . . . . . . . . . . . . . . . .
16
OTHER
17
(SPECIFY)
OK . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98--341
362
I YES............................. lj
DO y o u inter~¢l t o u s e a m e t h o d
w i t h i n t h e n e x t 12 rronthg'~
When y o u u s e a m e t h o d , w h i c h m e t h o d w o u l d y o u
p r e f e r t o use?
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
8
PILL ...........................
IUO . . . . . . . . . . . . . . . . . . . . . . . . . . . .
01
02
m
INJECTIO#4S ..................... 03
343
t~here c a n y o u g e t
(METNO0 MENTIONED IN 3 4 2 ) ?
]NTRAVAG. . . . . . . . . . . . . . . . . . . . . . .
CONDOM. . . . . . . . . . . . . . . . . . . . . . . . .
NORPLANT. . . . . . . . . . . . . . . . . . . . . . .
FEHALE STER[LIZATION. . . . . . . . . . .
MALE S T E R I L I Z A T I O N . . . . . . . . . . . . .
PERIO0]C ABSTINENCE . . . . . . . . . . . .
04
05
06
07
O~l
09
l l W I T . .H. . . .D. . . .R
OTHER
. . . .A
. . . . .W
.. A L
11~
ON,ORE
,
. . . . . .
. . . . . . . . . .
GOVERNMENT HOSPITAL . . . . . . . . . . . . .
PRIVATE HOSPITAL . . . . . . . . . . . . . . . .
HEALTH CENTER (PUSKESNAS) . . . . . . .
PRIVATE CL]N]C . . . . . . . . . . . . . . . . . .
HEALTH POST (POSYANDU) . . . . . . . . . .
FP POST/VCDC/pAGUyUBAN . . . . . . . . . .
FIELDWORKER (PLKB) . . . . . . . . . . . . . .
FP ~ ] L E
UN]T.(TKBK/TNK) . . . . . . .
(NAME OF PLACE)
PHARMACY~DRUGSTORE. . . . . . . . . . . . . .
PRIVATE DOCTOR. . . . . . . . . . . . . . . . . .
PRIVATE MIDWIFE . . . . . . . . . . . . . . . . .
TRAD%TIONAL HEALER (DUKUN) . . . . . .
FRIENDS/RELAT[VES . . . . . . . . . . . . . . .
FP SAFARI . . . . . . . . . . . . . . . . . . . . . . .
NC)WffERE. . . . . . . . . . . . . . . . . . . . . . . . .
OTHER
o,
I NO
Y" .............................
..............................
345
ghere
GOVERNMENT HOSPITAL . . . . . . . . . . . . .
PRIVATE HOSPITAL . . . . . . . . . . . . . . . .
HEALTH CENTER (PUSKESMAS) . . . . . . .
PRIVATE CLINIC ..................
HEALTH POST (POSYANDU) . . . . . . . . . .
is that?
FP P O S T / V C D C / P A G U Y U B A N . . . . . . . . . .
FIELDL~3RKER (PLKB) . . . . . . . . . . . . . .
FP MOBILE U N I T , ( T K B K / T M K ) . . . . . . .
PHARMACY/DRUGSTORE
..............
PRIVATE DOCTOR. . . . . . . . . . . . . . . . . .
PRIVATE MIDWIFE . . . . . . . . . . . . . . . . .
TRA,DITI(~CAL HEALER (DUKUN) . . . . . .
FRIENDS/RELATIVES . . . . . . . . . . . . . . .
FP SAFARI . . . . . . . . . . . . . . . . . . . . . . .
(NAME OF PLACE)
>3d.4
01
02 I
03
04
>3s,~5
05
0
07
O~>~dtB
09
10 /
11~->346
12
1 ~
14
>348
15
I
(SPECIFY)
DON'T KNOW. . . . . . . . . . . . . . . . . . . . . .
I
98
I
2-->348
01
02
03
04
03
06
07
Oe~J->~#~8
09 m
10
11
12
1~I
14
>348
~OWHERE......................... 15
OTHER
I
(SPECIFY)
J
14
213
NO.
HOW l o n g does I t t a k e t o t r a v e l
from your hoce to this place ~
346
SKiP
TO
COOING CATEGORIES
QUESTIONS AND FILTERS
MINUTES . . . . . . . . . . . . . . . . . .
1 J ~
HOURS. . . . . . . . . . . . . . . . . . . .
2
OK . . . . . . . . . . . . . . . . . . . . . . . . . . . .
346A
H. . . .
h dces t h e t r a v e l
cost~
COST ( R p ) :
I
I
998
I
I I
I
FREE . . . . . . . . . . . . . . . . . . . . . . .
DON tT KNOW. . . . . . . . . . . . . . . . .
347
I
I
348
Is it
easy or difficult
I
I
to 9et there~
Has a n y f ~ l L y
ptanning worker given you an explanation
a b o u t f a m i l y p t a f ~ l P ~ i n t h e l a s t s t x riTonths?
Any~>ne e i s e ?
CIRCLE ALL PERSONS WHO V I S I T E D
Have y o u e v e r h e a r d o f BLue C i r c L e ?
34~I
Can y o u t e [ t
I
I
me w h a t
it
I
157
I
EASY . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
DIFFICULT . . . . . . . . . . . . . . . . . . . . . . .
2
FIELD~RKER(SUB-DISTRiCT LEVEL),A
PKK (I~ONEN'S ORG,) . . . . . . . . . . . . . .
B
VCDC/PPKBO (VILLAGE LEVEL) . . . . . . C
CADRE . . . . . . . . . . . . . . . . . . . . . . . . . . .
D
NURSE . . . . . . . . . . . . . . . . . . . . . . . . . . .
E
MIDWIFE . . . . . . . . . . . . . . . . . . . . . . . . . F
OTHER
G
(SPECIFY)
I F YES: Who V l S I t C l d yOU?
348A
I
999
SURVEY QUESTIONNAIRES
SDKI91
]
SDKI91-RT
1991 I N D O N E S I A D~IMOGRAPHIC A N D H E A L T H S U R V E Y
HOUSEHOLD SCHEDULE
Confidential
IDENTIFICATION
i. P R O V I N C E
CODE
..........................................
2. R E G E N C Y / M U N I C I P A L I T Y
*) . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. S U B - D I S T R I C T
4. V I L I A G E
5. A R E A
. . . . . . . . . . . . . . . . . . . U R B A N - 1 ..... R U R A L -
D
D
2 **)
6. L A R G E C I T Y / S M A L L C I T Y / T O W N / C O U N T R Y S I D E .............
(Large city=l, S m a l l city=2, Town=3, C o u n t r y s i d e = 4 )
7. E N U M E R A T I O N A R E A N U M B E R
8. S P 9 0 S A M P L E C O D E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9. I D H S 9 1 S A M P L E C O D E . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
L0. H O U S E H O L D
NUMBER ................................................
Ll. N A M E O F H O U S E H O L D
HEAD
INTERVIEWER
1
VISITS
2
FINAL VISIT
MONTH
DATE
.................
INTERVIEWER'S
N A M E ....
S
INTERV.
FINAL RESULT
AL ERII
DATE
OF VISITS
TIME
***) R E S U L T CODES:
1 COMPLETED
2 H O U S E H O L D P R E S E N T BUT N O C O M P E T E N T RESP. A T H O M E
3 HOUSEHOLD ABSENT
4 POSTPONED
5 REFUSED
6 D W E L L I N G V A C A N T O R A D D R E S S t40T A D W E L L I N G
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER
T O T A L IN
HOUSEHOLD
TOTAL
ELIGIBLE
WOMEN
DATE IFIEEDIOBYIoFIEOIOBYI YEOBY
*)
**)
***)
--
YE~.R
R E S U L T ***) ...........
N E X T VISIT:
~
Cross out category not used
Circle selected category
Choose suitable result
195
I KEYEDBY
HOUSEHOLD
NO¢4 ~e UOULd h k e soe~e i n f o r m a t i o n abo~t t h e p e o p l e teho u s u a l l y
NO,
USUAL RESIDENTS
hve
In your" h o u s e h o l d ,
1 I'oe
I
TO HEAD OF
m HOUSEHOLD
EDUCAT[OI4
FOR ALL PERSONS AGED 5 AND ABOVE
--|
P l e a s e g { v e me t h e names
o f t h e persons hho u s u a l l y
t i r e i n your h o u s e h o l d ,
s t a r t i n g w i t h t h e heed o f
the household,
(1)
I I
What IS
the
relationship of
i (HARE) 1,o
i t h e head
; of the
, househotd?'
(2)
Is (NM4E)
m a l e or"
female?
(4)
(5)
I
I
H
IT1
Has
What i s t h e
(NANA)
highest
ever
' Level o f
been t o
school
schooL?
(NANE)
a t t ended~**
FO~ALL
PERSO~4SAGED
LESS THAN
25 YEARS
[s (NAME)
(3)
I
HOW o l d
IS
(MANE)?
,2
f
(6)
I
YEARS
IT1
•11at ~S t h e
highest
grade
=ot~pl e t ed? t t
(7)
st{It in
schooL?
.EVEL
YES
I
YES
NO
GRADE
E
(8)
NO
1
2
t
2
1
2
t
2
2
Z
o,
rl-l.,
F
Z
Z
2
2
2
2
[
COOES FOR COLUMN ( 3 ) :
RELATIO~SH[P TO HEAD OF HOUSEHOLD:
01= HEAD OF HOUSEHOLD
02= ~IFE OR HUSBAND
03 = CHILD
04= SON OR DAUGHTER-IN-LAW
05= GRANDCHILD
06 = PARENT
07= PARENT-]N-LA~
08= BROTHER OR SISTER
09 = OTHER RELATIVE
10= ADOPTED/FOSIER CHILO
11 = NOT RELATED
98= OK
196
t
E
1
2
I
Z
= ' ) COOES FOR COLLmqt~( 7 ) :
LEVEL OF EDUCATiOn:
1= PRlidARY
2 = JUNIOR HIGH
3= SENIOR HIGH
4= ACADENY/UNI VERS[ Iy
8 = DK
GRADE:
0 = LESS THAN 1 YEAR CQMPLE1ED
8= DK
SCHEDULE
FOSTERING***
NARXTAL
$1AtU$
ELIGIBILITY
IF AGED LESS THA~ 15 YEARS
IF ALIVE
Is (MANE)'=
p~turat
it~ther alive9
19)
,
:YES
NO
Does (NANE)'s
natural mother
Live in this
ho~mehotd?
I
O
I I
8
IF YES;
k~lat i s h e r p,e~e?
IF YES:
I~hlt tS b i b r~l~t~
RECORD NOTHER'S
L]NE NUMBER
RECORD FATHER=S
LINE NUMBER
110)
MO
AGED 10
AND ABOVE
CIRCLE LINE
~LM~E~ OE A~L
EVER'MARRIED
tdO#EN AGED
15-49
Has (NAME)
ever be~
married?
112)
(11)
YES
DK
1
IF ALIVE
Is IN~E)'=
,
natural
Does (I~AJ4E)' s
f a t h e r a l i v e ? r~lmttJra=l f a t h e r
live tn thtli
hOU~eho[dT
OK
(16)
113)
YES
NO
01
02
I
1
8
1
8
1
8
1
8
1
8
,
E
~-]
03
O~
1
o
J-~
OS
O6
07
1
1
8
1
8
1
8
1
8i
1
8
1
E
1
O
1
E
"*')
Oa
10
I
'
°i
1
o
o
J-~
J~
1
11
1
12
1
13
1
16
1
15
Th{£ ~ s t i ~
refers to the biological parents of the child.
Record *00 ~ t f p a r e n t n o t m e e t ~ r o f t h e h o u s e h o l d .
r--7
JJ
TICK HERE IF CONTINUATI~ SHEET USED
~t
TOTAL ML~4BEROF ELIBIBLE VJ(]MEN
171
t o T~l~ke $~re I have ~ c o m p l e t e l l $ t i r ~ ] :
1) A r e t h e r e any p e r s o n s such as sma~l c h ~ I d r e n o r
i n f a n t s thet ~ h a v e n o t l i s t e d ?
2) A r e t h e r e any o t h e r p e o p l e i~ho may n o t be memL~rs o f yc~Jr f a m i l y ,
like servants, friend,
l o d g e r s , t:=Jt who u s ~ l l y
l i v e here~
3) A r e t h e r e any o t h e r g ~ i t B or V i s i t o r s who h a v e been
t e c p o r a r t [ y s t a y i n g M i t h you f o r t h e p a s t 6 months o r more?
4) Are t h e r e any persons who u s u a l l y
f o r l e s s t h a n 6 month=?
l i v e h e r e kho h a v e been away f o r
5) A r e t h e r e any p e r s o n s ~e h a v e l i s t e d
p o s t 6 months?
Who have been a~ay f o r t h e
,Es D - . E ~ , .
,,OH ,, EA,~E
YES ER.E,,E, E" "'"LE
'E$ ER'E'TER
" '''LE
'o I--7
'o8
NO.
QUESTIONS AND FILTERS
15
U h e t t s t h e souPce o f ~ a t e r y o u r h o ~ e h o l d
f o r h a n d ~ a s h l n g and d t s h N a s h i n g ?
I
16 I
I
17
18
19
20
Hc~ t o n g does t t
and c o ~ b a c k ?
t a k e t o go t h e r e ,
22
~es
get water,
Does y o u r h o u s e h o l d g e t d r i n k i n g
. f r o m t h i s same ~ o u r c e ?
uater
~8t
is the source of drinking water
f o r members o f y o u r h o u s e h o l d ?
~dhat k i n d o f
toilet
facitity
does y ~ u r h o u s e h o t d have?
IdELL . . . . . . . . . . . . . . . . . . . . . . . . . . .
SPRING . . . . . . . . . . . . . . . . . . . . . . . . .
RIVER . . . . . . . . . . . . . . . . . . . . . . . . . .
RAINWATER . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
05
MINUTES . . . . . . . . . . . . . . . . .
06
07
08
09
I
[
~qAIg MATERIAL OF THE FLOOR.
198
t
1-->19
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Z
PIPED INTO RESIDENCE . . . . . . . . . . .
PIPED INTO YARD OR PLOT . . . . . . . .
PUBLIC TAP . . . . . . . . . . . . . . . . . . . . .
p~p ...........................
WELL . . . . . . . . . . . . . . . . . . . . . . . . . . .
SPRING . . . . . . . . . . . . . . . . . . . . . . . . .
RIVER . . . . . . . . . . . . . . . . . . . . . . . . . .
RA I M~/ATER. . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
01
02
03
04
OS
PRIVATE, W. SEPTXE TANK . . . . . . . . .
PRIVATE, NO SEPTIC TANK . . . . . . . . .
$HARED/PU8L]C . . . . . . . . . . . . . . . . . . .
01HER
(SPECIFY)
1
2
3
BICYCLE/BOAT . . . . . . . . . . . . . . .
I~TOR VEHICLE . . . . . . . . . . . . . .
TILE . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONCRETE/BRICK . . . . . . . . . . . . . . . . . .
............................
BANBO0 . . . . . . . . . . . . . . . . . . . . . . . . . .
DIRT/EARTH . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
(RECORO 06SERVATTO~.)
~
996
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ELECTRICITY . . . . . . . . . . . . . . . .
RADIO OR CASSETTE . . . . . . . . . .
TELEVISIO~ . . . . . . . . . . . . . . . . .
STOVE . . . . . . . . . . . . . . . . . . . . . .
O ~ s a n y member o f y o u r h o u s e h o l d h a v e o r h a v e
access to:
A bicycLe/boat?
A mtor vehicle?
I
01"-'-- I
02~>17
03
Does y o u r house h a v e :
Stove?
,o
PIPED INTO RESIDENCE . . . . . . . . . . .
P[PED INTO YARD OR PLOT . . . . . . . .
PUBLIC TAP . . . . . . . . . . . . . . . . . . . . .
PREN]SES . . . . . . . . . . . . . . . . . . .
ELectricity?
A radio or cassette?
A television?
A gas, kerosene or electric
21
I
COOING CATEGC~IES
06
07
08
09
4
YES
NO
1
1
1
1
2
2
Z
2
YES
1
1
NO I
2
2
1
2
3
6
E
6
I
t
i SDKI91
i
SDKI91-WK
1991 I N D O N E S I A D ~ 0 G R A P H I C
AND HEALTH SURVEy
INDIVIDUAL WOMAN'S QUESTIONNAIRE
Confidential
IDE~TIFICATION
1. P R O V I N C E
CODE
.................
2. R E G E N C y / M U N I C I P A L I T Y
*)...
3. S U B - D I S T R I C T
4. V I L L A G E
5.
. .UP/~AN
AREA
- 1 ..... R U R A L -
D
[]
2 **)
6. L A R G E C I T Y / S M A L L C I T Y / T O W N / C O U N T R Y S I D E .............
(Large city=l, S m a l l city=2, T o w n = 3 , C o u n t r y s i d e = 4 )
7. E~qUMERATION A R E A N U M B E R
8.
V--r--7--q
SP90 SAMPLE CODE ................................................
9. I D H S 9 1 S A M P L E C O D E
~ER...IIIIIIIIIIIIIIIIIIIIIIIIIIIIIIII I iiiiiiiiiiii
10 .oosENo~
ii. NA24E O F H O U S ~ O I / )
H~
12. L I N E NI24BER O F W O M A N F R O M H O U S E N O L D S C H E D U L E . . . . . . . . . . . . . . . . . . . . . . .
i
13. N A M E O F W O M A N
INTERVIEWER
VISITS
2
DATE
FINAL VISIT
.................
INTERVIEWER'S
INTERV.
N A M E ....
I ~ U L T ***) . . . . . . . . . . .
FINAL RESULT
I
INEXTVISIT:
DATE
TOTAL NUMBER
OF VISITS
TIME
***) R E S U L T CODES:
1 COMPI~TED
2 NOT AT HONE
3 POSTPONED
NAME
DATE
*)
**)
***)
I
4 REFUSED
5 PARTLY COMPLETED
6 OTHER
l°
Cross out category not used
Circle selected category
Choose suitable result
199
I
I
[]
200
I SECTI~ I .
NO. I
RESFGMDENT'SBACKGROUNDI
I
~JESTIO~S AND FILTERS
I S~IP
TO
COOING CATEGORIES
i
F i r s t % UOuLd l i k e to ask io~equestion= about you.
For mos¢ of the tir~e u n t i l you v~re 12 years old, dLd
you l i v e i n a vftLage, in n t ~ .
or in m c i t y ?
102
CITY . . . . . . . . . .
• TOiJN. . . . . . . . . . . . . . . . . . . . . . . . . . . .
VILLAGE . . . . . . .
.1
E .
3
103 II In i~'~atmor~thandyear w~re you born?
IF l~qTHNOT IN i4ESTERNCALENDAR,W lTENAME:
I
.
.
.
.
.
GO~PARE AND CO~RECT 10] AND/(Xq 104 [F INCOI4SISTENT.
IF AGE LESS THAN 15 (~ 5 ~ , END iNTERVIEW.
104A I
Are y~J ~ow meJrrted, uidowed, or dIvorce~?
14ARR%ED. . . . . . . . . . . . . . . . . . . . . . . . .
O%VOICED. . . . . . . . . . . . . . . . . . . . . . . .
I
106 I
I
I
107 I
I
108 I
_ _ 0
1 I
2
I
.........................
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->109
Q/hat is the highest Level of school you attended:
primary, j u n i o r high, senior high, acad¢t~, or
university?
PRIMARy. . . . . . . . . . . . . . . . . . . . . . . . .
JUN%0~ HIGH SCHOOL. . . . . . . . . . . . . .
SENIOR HIGH SCHOOL. . . . . . . . . . . . . .
ACADEMY/UNIVERSITY. . . . . . . . . . . . . .
1
2
3
4
t h a t is the hLghest (GRADE, FGRM, YEAR) you completed
I t t h l t level?
GRJ~OE. . . . . . . . . . . . . . . . . . . . . . . . .
CHECR 106:
E~
D
JUXI{~ HiGH
PRIMARY
OR HIGHER
i
V
>110
I
109
110
111
]
cart you reed and understand a Letter or r-~wspeper
e a i i [ y , = l t h d i f f i c u l t y , or not ot a(L?
DO you~suaLty read a newipaper or musgazLr~ at Least
orice a ~eek?
Do yov.r USL~lLy [ i S t ~
tO the radio every d~ay?
11Z
Do
l you
e a -L~s~t
-ak ? sty watch
t
c t e l e~v i s i oe n . t
113
~lhat r e l i g i o n are yo~J?
EASILY . . . . . . . . . . . . . . . . . . . . . . . . . .
WITH DIFFICULTY. . . . . . . . . . . . . . . . .
MOT AT ALL . . . . . . . . . . . . . . . . . . . . . .
I
I
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
I
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 I
I
..............................
2
I
YES.N.O
.........................................................
21
i
MUSLIM. . . . . . . . . . . . . . . . . . . .. .. .. .. .. .. .. . . . . .
PROTESTANT/CHRISTIAN
CATKOLIC. . . . . . . . . . . . . . . . . . . . . . . .
HINDU. . . . . . . . . . . . . . . . . . . . . . . . . . .
BUDDHIST. . . . . . . . . . . . . . . . . . . . . . . .
OTHER
(SPEC%FY)
2I
]
4
5
6
I
I
I
201
I
E I
3~>111
I
NO
I
SECT]ON 2,
REPROOUCT]Ce4I
QUESTIONS AND FILTERS
~
o i N
' ~ l~ rLE~~ ourSe •t ° hs H- e- t y~
a e ethe~
d l e o th~ rYt h~ h - -
~0,j Ho,~.oy.... i ..... ~hyoo,
I
SKIP
I TO
CODING CATEGORIES
............................. I
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->206
WO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->20~
I s°NBAT- ............... ~l
And hOW many d a u g h t e r s L i v e w i t h you?
DAUGHTERS AT HOI4E. . . . . . . . . .
IF
HONE ENTER ' O 0 ' ,
given birth
who a r e a l i v e b v t do n o t l i v e w i t h you7
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I
206 J
I
207
And hofl m~ny d a u g h t e r s are a l i v e ~ J t ~
you "~
COt t i r e
2-->206
with
DAUGHTERSELSEUNERE. . . . . . . .
[F NONE ENTER *00 I .
Have
born
baby
only
you e v e r g i v e n b i r t h t o a boy o r a g i r t who was
8 l i v e b u t l a t e r d i e d ? IF NO. PROBE: Any ( o t h e r )
~ho c r i e d o r sho~ad any s i g n o f ~ i f e b u t
s u r v i v e d a few hours o r days?
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 I
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2-->208
I
I
] n a l l , hOW m~ny boys h a v e d i e d ?
And how many 9 i r ~ s h a v e d i e d ?
[F NONE ENTER ' 0 0 ~.
SUN ANSWERS TO 203, 205, AND 207, AND ENTER TOTAL.
TOTAL . . . . . . . . . . . . . . . . . . . . . .
[F NONE ENTER JOB I .
2O9
CHECK 208:
J u s t t o rPake sure t h a t I have t h i s
your L i f e . I s t h a t c o r r e c t ~
IES ~
NO i
r~gh~: you have had i n TOTAL -
l
-
Live births
(~Jrtr~J
PROBE AWD
• CDeREC1 201-209 AS ~ECESSARY
/
V
210
CHECK 208:
ONE OR HORE [ ~
hO BIRTHS ~ ]
>225
I
202
211
NC~ I Would Like t o t a l k t o you about a l l
f i r s t on~ you had.
(RECORD NA~4ES OF ALL THE BIRTHS iN 212,
212
213
Jhat ne~e was
~iven t o y o u r
(flrst,r~xt)
~aby~
whether s t i l l
a l i v e or not, s t a r t i n g
with the
RECORDTWINS AND TRIPLETS ON SEPARATE LINES).
21&
215
216
[s
(NAME)
a boy o r
a 9irt?
I n what r ~ n t h
IsncI y e a r Was
(NAME) born?
IS (N/d4E) HOW o l d WaS
StiLL
; ( N ~ E ) at
alive?
: his/her last
b l r t hday?
RECORD
SINGLE
OR
WtJLTIPLE
BIRTH
STATUS
o!I
o f yc*Jr b i r t h s j
21}'
IF ALIVE:
PROBE:
~11at i s h i s /
h e r bi r t h d a y~
OR: I n wt~at
seoson?
21B
IF ALIVE:
220
IF DEAD:
I s (NAME)
[LvIn~
w i t h yc4J?
HOW o t d was h e / s h e
when he/she dlC'~d?
IF -1 y R . - PR~E:
HOW rlzany IPO~ths
o l d was (MANE)?
RECORD AGE
IN COMPLETED
YEARS
SING..,1
BOY,..1
MX~NTH,. ~
YES'''1
MOLT...2
GIRL..2
TEAR..*
NO....2
J
(NAME)
RECORD DAYS IF LESS
THAN I RO¢~T½,NONTHS
[F LESS THAN ll~K~
YEARS, ~ YEARS.
IF LESS THAW I~qE
DAY, W~ITE *00'
OAYS, . . , 1
AGEyEARsIN
YES. . . . . . .
MONTHS,.2
~ l
NO. . . . . . . . 2
(GO TO NEXT
BIRTH)"
NO. . . . . . . . 2
(GO TO NEXT
I,~,ONTHS..2
BIRTH)<
YEARS...3
v
22O
1
YEARS,. ,3
(NAME)
2ZO
%
M,
ULT...2
GIRL..E
YEAR...
NO....2
I
( NJzi'4E)
;
YEARS
F ~
v
ZEO
j
~
%
(NAME)
220
BOY,, ,~
MONTH.,
YES...)
M~JLT...2 , GIRL..2
SING,.,1
YEAR...
NO....2
I
(NAME)
v
AGE IN
YEARS
III
YES. . . . . . .
]
1
DAYS....
1
NO. . . . . . . . 2
(GO 10 NEXT
BIRTH)<
k~O~TRS.. 2
NO. . . . . . . . 2
(GO TO NEXT
BIRTH)(
HOWlHS. ,2
YEARS...3
22C
(NAME)
220
SING,, ,1
BOY...1
MONTH..
YES,..1
MULT...2
G]RL..2
YEAR...
NO. , . ,2
I
(NAME)
v
220
203
AGE iN
YEARS
YEARS...3
212
213
~ B t rt~T~ W&s
gJvc~rl tO your
(first,next)
baby~
214
215
216
217
IF ALIVE:
E18
IF ALIVE:
220
IF DEAD:
Is
INANE)
a boy o r
8 girl ~
I n ~ a t J~C~th
a r d year was
(NARE) born?
IS INANE)
stilt
alive?
HOW o l d was
(NAME) a t
his/her fast
birthday?
I s (NANE)
living
~ i t h you ?
How o l d was h e / s h e
~hen h e / s h e d i e d ?
RECORD
SINGLE
OR
NULT]PLE
BERTH
PROBE:
g h a t IS h i s /
her b i r t h d a y ?
OR: [n wh~t
season?
IF " 1 Y R , " , PROBE:
HO~ many months
o l d wes (NAME)?
RECORD AGE
IN CO)4PLETED
YEARS
REC(~D DAYS IF LESS
THAN 1MONTH,HOMTB$
IF LESS THAN Tl~O
YEARS, OR YEARS.
IF LESS THAN O~E
DAY, ~P[TE DBO~
STATUS
8]
SING...1
BOY.,.1
HONTH.,
YES..,1
14ULT.,.2
GIRL,,2
YEAR..,
NO.,.,2
J
AGE [N
YEARS
22O
( NAJ4E)
[ ~
v
09•
SING,..1
BOY,.,1
NONZH..
YES...1
i
MULT..,2
G]RL,,2
YEAR.,.
NO....2
J
J
INANE)
v i
AGE IN
YEARS
~
ill
220
SZNG...1
BOY, . , 1
~TH..
NULT, . ,2
G]~L..2
YEAR* , .
]
I
(NAME)
~J
AGE IM
YEARS
SING, , . 1
BOy... 1
MONTH.. ~ 1 ~
YES.,.1
K4JLT...E
G[RL,.E
YEAR,.,
NO,,.,E
J
v
220
(NAI4E)
12J
YES...1
NO, , , .2
J
v
2CO
i
SING...1
BOY,. , I i V~NTH..J
V/JLT,,.2
G[RL..E i YEAR,..
I,
[NAME)
J
J
yES...1
NO.,.,2
J
SING...1
BOY...1
NONTH.. ~ [ ~
YES...1
~JLT . . .2
GIRL. ,2
YEAR. , ,
NO. , . ,2
DAYS''''1
V~NTHS..E
YES. . . . . . .
DAYS''''1
1,
YEARS,.,3
NO. . . . . . . . 2(GO TO NEXT
BIRTH)(
MONTHS,.2
YES. . . . . . .
DAYS'''*1
1-
YEARS...3
NO. . . . . . . . 2
(GO TO NEXT
B]RTB),-
MOflTBS,.2
YES. . . . . . .
BAYS..,,1
[ ~
AGE IN
YEARS
~
ill
AGE IN
YEARS
J
v
(NAME)
1,
NO. . . . . . . . 2,
(C'OTO NEXT
BIRTH)326
SK[P
NO.
OUEST[ONS AND FILLERS
~7
l TO
COOTNG CATEGORIES
l
Are you h a v i n g ~ny h e a l t h probLen~ i n u s i n g
(CURRENT METHOD)?
.............................
, t
2-->328A
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
328
~ h a t t s t h e ma+n h e a r t h probtam~
Are y o ~ h a v l n g a n y o t h e r p r o b [ ~
(CURRENT METHOD)?
328/~
328B
~EIGHT GAIN . . . . . . . . . . . . . . . . . . . .
~EIGHT LOSS. . . . . . . . . . . . . . . . . . . .
BLEEDZNG. . . . . . . . . . . . . . . . . . . . . . .
HVPERTENSIQ~. . . . . . . . . . . . . . . . . . .
HEADACHE. . . . . . . . . . . . . . . . . . . . . . .
NAUSEA. . . . . . . . . . . . . . . . . . . . . . . . .
A~ENORRHEA. . . . . . . . . . . . . . . . . . . . .
IgEAK/TIRED. . . . . . . . . . . . . . . . . . . . .
OTHER
(SPECIFY)
D~ . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
I n u~ing
~Jhat I s t h e I1~1n p r o b [ ¢ ~
01
02
O~
04
05
06
O~
08
09
98
YES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2--~329
HUSBAND OIBAPPROVES. . . . . . . . . . . .
ACCESS/AVAILABILITY . . . . . . . . . . . .
COSTS TOO~LJCN. . . . . . . . . . . . . . . . .
INCONVENIENT TO USE . . . . . . . . . . . .
STERILIZED,
~ANT$ C½[LDREN. . . . . . . . . . . . . . . .
OTHER
(SPEC%FY)
OK. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
01
02
03
01.,
OS
06
98
CHECK 315 AND 321:
329
STERIL)ZED BEFORE JANUARY 1986
I
NEITHER
STERILIZED
[~
STERIL]ZED SINCE JANUARY 1966
I
~348
I~
>331
L
iii V
330
ENIER NETHCX) CODE FRC~4315 IN CURRENT MONTH IN COLI1 OF CALENDAR. THEN DETERMINE WHEN SHE
STARTED USING THIS METHOD THIS TIME. ENTER METHOD COOE IN EACH MONTH OF USE,
ILLUBTRATIVE QUESTIONS:
tCnen d i d you s t a r t u s i n g t h i s method c o n t i n u o u s l y ?
HOW Tong have you been u s i n g t h i s method contlnuo~sLy~
33~
would ~ik~ to a~k some ~est~on~ about all of the (other} periods in the fast few years
dIJring ~.hlCh you used a rc~thod t o avoid g e t t i n g p r e g n a n t .
USE CALENDAR TO PROBE FOR EARL]ER PERICOS OF USE AND NI~flUSE, STARTING W]TH HOST RECENT
USE, BACK TO JANUARY 1986.
USE NAJ4ES OF CHILDREN, DATES OF GIRTH, AND PERIOOS OF PREGNANCY AS REFERENCE POINTS.
IN EACH MONTH, ENTER CCOE FOR NETHCO OR -O- FOR NONUSE IN COLIJNN 1.
ENTER COORS FOR DISCONT]NUANON NEXT TO LAST VA)NTH OF USE.
[N COLUMN 2,
NLR45ER OF COOES ENTERED IN COLUMN 2 NJST BE THE SANE AS
THE NUI4BEROF INTERRUPTIONSOF CONTRACEPTIVE USE IN COLL~4N t
ASK UHy SHE STOPPED USING IRE METHO0. iF A PREGNANCY FOLLO~IED, ASK WHETHER SHE
9ECAME PREGNANT UNINTENTIONALLY WHILE USING THE METHO0 OR DELIBERATELY STOPPED
TO GET PREGNANT.
ILLUSTRATIVE OUESTIONS:
COLL~IN 1:
-When was the Last t i e
you used a ¢nethod~ Which method vas t h a t ?
-When d i d you s t a r t u s i n g t h a t method~ HOW tong a f t e r the b i r t h o f (NANE)~
-HOW long d i d yc~ use the ~ t h o d then?
COLUI4N 2:
*Why d i d yC*J s t o p uSing the (METHI~)*P
- D i d you I~cc~e pregnant w h l ( e u s i n g (NETHO0), Or d i d you s t o p t o get pregnant~
o r s t o p f o r soq~ o t h e r reason?
IF DELIBERATELY STOPPED 10 BECC~4E PREGNANT, ASK:
-HOW fl~n¥ n x ~ t h $ d i d I t take you t o get pregnant a f t e r you stopped u s i n g (METHO0)?
AND ENTER - 0 - IN EACH SUCH MONTH IN COLUNM 1.
12
211
SKiP
.o. j
COUIN~, CA I EI~O~I ES
UUE~ILON~ AND f l l l L ~
I io
CHECK CALENDAR:
NO METHOD USED
[N MONTH OF JAN. 1986
METHOD USED IN NONTH OF JAN* 1986
V
[ see t h a t
333
you were usir~
~Jher~ d i d yc~J s t a r t
using
(NETHQD] i n J a n ,
(METH(~}) t h a t
1986.
tlt~ ~
MO~TH . . . . . . . . . . . . . . . . . . . . . .
YEAR . . . . . . . . . . . . . . . . . . . . . . .
[ ~ . J
>$38
k~l
( T H I S DATE SHOULD NOT PRECEDE THE DATE OF BIRTH
OF ANY CHILD BORN BEFORE JAN. 1986)
334
I see t h a t y o u were r ~ t u ~ l n g a n y r~ethod
of contraceptl¢~
I n J a n . 1986.
Did yc~ ever use
a r~*thod before thnt?
I|
!
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2--~3~d3
I
335
CHECK 215;
½KD BIRTH
BEFORE JAN. 1986
I YES.............................
D i d yOU u s e a m e t h o d b e t w e e n t h e b i r t h o f
(NAME OF LAST CHILD BOR~ BEFORE JAN. 1986)
a n d J a n . 1986?
336
337
NO B[RTH
BEFORE JAN. 1986
I
When d i d y o u s t o p u s i n g
p r i o r t o Jan. 1986?
the
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
' I
2-->3~
Last tllE~
I- ......................
YEAR
. . . . . . . . . . . . . . . . . . . . . . .
13
212
NO.
338
QUESTIOHS AND FILTERS
CO0)NG CATEGORIES
I
CURRENTLY
I
NETHO0
I
CURRENTLY USING PERIO01C A6STINENCE
METH~ITHDRAWAL'
OTHER TRADITIONAL
~v
CHECK 3 1 5 :
USINGNOT
CURRENTLYA
METXOD
I
~
USING A NOOERN [ ~
(SKIP TO 344)
SKIP
TO
>3!.~
I
V
339
340
DO you I n t e ~
t o use a ~ t h o d t o d e [ e y
pregnancy at any time in the future?
Whot i s t h e ~ l n
a method?
reas~
y~
®
not
o r ovoid
intend
to use
I
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1-->341
NO ..............................
2
DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
WANTS CHILDREN. . . . . . . . . . . . . . . . .
LACK OF KNtTALEDGE. . . . . . . . . . . . . .
PARTNER OPPOSED. . . . . . . . . . . . . . . .
'
I
>344
0182
03
04
05
06
07
COST TOO MUCH. . . . . . . . . . . . . . . . . .
SIDE EFFECTS . . . . . . . . . . . . . . . . . . .
HEALTH CO~¢CERNS. . . . . . . . . . . . . . . .
HARD TO GET METHODS. . . . . . . . . . . .
RELIGIO(d . . . . . . . . . . . . . . . . . . . . . . .
OPPOSED TO FAMILy P L A N N I N G , . , . , 0 9
FATALISTIC . . . . . . . . . . . . . . . . . . . . .
10
RELATIVES OPPOSED . . . . . . . . . . . . . .
11
INFREQUENT SEX . . . . . . . . . . . . . . . . .
12
DIFFICULT TO GET PREGNANT. . . . . . 13
NENO@AUSAL/HADHYSTERECTOMY.,..1&
INCONVENIENT. . . . . . . . . . . . . . . . . . .
13
NOT MARRIED. . . . . . . . . . . . . . . . . . . .
16
OTHER
17
(SPECIFY)
OK . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
98--341
362
I YES............................. lj
DO y o u inter~¢l t o u s e a m e t h o d
w i t h i n t h e n e x t 12 rronthg'~
When y o u u s e a m e t h o d , w h i c h m e t h o d w o u l d y o u
p r e f e r t o use?
NO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
8
PILL ...........................
IUO . . . . . . . . . . . . . . . . . . . . . . . . . . . .
01
02
m
INJECTIO#4S ..................... 03
343
t~here c a n y o u g e t
(METNO0 MENTIONED IN 3 4 2 ) ?
]NTRAVAG. . . . . . . . . . . . . . . . . . . . . . .
CONDOM. . . . . . . . . . . . . . . . . . . . . . . . .
NORPLANT. . . . . . . . . . . . . . . . . . . . . . .
FEHALE STER[LIZATION. . . . . . . . . . .
MALE S T E R I L I Z A T I O N . . . . . . . . . . . . .
PERIO0]C ABSTINENCE . . . . . . . . . . . .
04
05
06
07
O~l
09
l l W I T . .H. . . .D. . . .R
OTHER
. . . .A
. . . . .W
.. A L
11~
ON,ORE
,
. . . . . .
. . . . . . . . . .
GOVERNMENT HOSPITAL . . . . . . . . . . . . .
PRIVATE HOSPITAL . . . . . . . . . . . . . . . .
HEALTH CENTER (PUSKESNAS) . . . . . . .
PRIVATE CL]N]C . . . . . . . . . . . . . . . . . .
HEALTH POST (POSYANDU) . . . . . . . . . .
FP POST/VCDC/pAGUyUBAN . . . . . . . . . .
FIELDWORKER (PLKB) . . . . . . . . . . . . . .
FP ~ ] L E
UN]T.(TKBK/TNK) . . . . . . .
(NAME OF PLACE)
PHARMACY~DRUGSTORE. . . . . . . . . . . . . .
PRIVATE DOCTOR. . . . . . . . . . . . . . . . . .
PRIVATE MIDWIFE . . . . . . . . . . . . . . . . .
TRAD%TIONAL HEALER (DUKUN) . . . . . .
FRIENDS/RELAT[VES . . . . . . . . . . . . . . .
FP SAFARI . . . . . . . . . . . . . . . . . . . . . . .
NC)WffERE. . . . . . . . . . . . . . . . . . . . . . . . .
OTHER
o,
I NO
Y" .............................
..............................
345
ghere
GOVERNMENT HOSPITAL . . . . . . . . . . . . .
PRIVATE HOSPITAL . . . . . . . . . . . . . . . .
HEALTH CENTER (PUSKESMAS) . . . . . . .
PRIVATE CLINIC ..................
HEALTH POST (POSYANDU) . . . . . . . . . .
is that?
FP P O S T / V C D C / P A G U Y U B A N . . . . . . . . . .
FIELDL~3RKER (PLKB) . . . . . . . . . . . . . .
FP MOBILE U N I T , ( T K B K / T M K ) . . . . . . .
PHARMACY/DRUGSTORE
..............
PRIVATE DOCTOR. . . . . . . . . . . . . . . . . .
PRIVATE MIDWIFE . . . . . . . . . . . . . . . . .
TRA,DITI(~CAL HEALER (DUKUN) . . . . . .
FRIENDS/RELATIVES . . . . . . . . . . . . . . .
FP SAFARI . . . . . . . . . . . . . . . . . . . . . . .
(NAME OF PLACE)
>3d.4
01
02 I
03
04
>3s,~5
05
0
07
O~>~dtB
09
10 /
11~->346
12
1 ~
14
>348
15
I
(SPECIFY)
DON'T KNOW. . . . . . . . . . . . . . . . . . . . . .
I
98
I
2-->348
01
02
03
04
03
06
07
Oe~J->~#~8
09 m
10
11
12
1~I
14
>348
~OWHERE......................... 15
OTHER
I
(SPECIFY)
J
14
213
NO.
HOW l o n g does I t t a k e t o t r a v e l
from your hoce to this place ~
346
SKiP
TO
COOING CATEGORIES
QUESTIONS AND FILTERS
MINUTES . . . . . . . . . . . . . . . . . .
1 J ~
HOURS. . . . . . . . . . . . . . . . . . . .
2
OK . . . . . . . . . . . . . . . . . . . . . . . . . . . .
346A
H. . . .
h dces t h e t r a v e l
cost~
COST ( R p ) :
I
I
998
I
I I
I
FREE . . . . . . . . . . . . . . . . . . . . . . .
DON tT KNOW. . . . . . . . . . . . . . . . .
347
I
I
348
Is it
easy or difficult
I
I
to 9et there~
Has a n y f ~ l L y
ptanning worker given you an explanation
a b o u t f a m i l y p t a f ~ l P ~ i n t h e l a s t s t x riTonths?
Any~>ne e i s e ?
CIRCLE ALL PERSONS WHO V I S I T E D
Have y o u e v e r h e a r d o f BLue C i r c L e ?
34~I
Can y o u t e [ t
I
I
me w h a t
it
I
157
I
EASY . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
DIFFICULT . . . . . . . . . . . . . . . . . . . . . . .
2
FIELD~RKER(SUB-DISTRiCT LEVEL),A
PKK (I~ONEN'S ORG,) . . . . . . . . . . . . . .
B
VCDC/PPKBO (VILLAGE LEVEL) . . . . . . C
CADRE . . . . . . . . . . . . . . . . . . . . . . . . . . .
D
NURSE . . . . . . . . . . . . . . . . . . . . . . . . . . .
E
MIDWIFE . . . . . . . . . . . . . . . . . . . . . . . . . F
OTHER
G
(SPECIFY)
I F YES: Who V l S I t C l d yOU?
348A
I
999