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



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