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Republic of Indonesia
BPS Statistics of Indonesia
2005 Intercensal Population Survey
Sample Survey

SUPASO5 - S

I. Location identification

101. Province _ _
102. Regency/municipality _ _
103. Sub-district _ _ _
104. Village _ _ _
105. Village classification _

[] 1 Urban
[] 2 Rural

106.

____ A. Census block number
____ B. Sub-census block number

107. Sample code number _ _ _ _
108. Physical building number/census building number

____ PBN
____ CBN

109. Selected household number _ _

II. Summary

201. ____ Name of the head of household

202. _ _ Number of household members

203. _ _ Number of household members age 5 or older

204. _ _ Number of household members age 10 or older

205. _ _ Number of household members age 60 or older

206. _ _ Number of ever married women age 10 or older

207. _ _ Number of dead people

III. Enumerator particulars

301. ID number of enumerator _ _ _ _ _

302. Type of enumerator _

[] 1 BPS staff
[] 2 Subdistrict census coordinator
[] 3 Temporary personnel

303. Enumerator statement: I take seriously the task of filling out this questionnaire pursuant to the interview with the respondent of household members

____ Date
____ Signature name

304. ID number of supervisor _ _ _ _ _

305. Type of supervisor _

[] 1 BPS staff
[] 2 Subdistrict census coordinator
[] 3 Temporary personnel

306. Supervisor statement: This questionnaire is really in my observation and I have checked it according to the guidance book

____ Date
____ Signature name

IV.A. List of household members

401. Who usually lives and eats in this household [including all] adults, children, or babies?

Name of household member ____

402. What is the relationship of [the respondent] to the head of the household?

[] 1 Head of household
[] 2 Spouse
[] 3 Child
[] 4 Son/daughter in law
[] 5 Grandchild
[] 6 Parent/parent in law
[] 7 Other relative
[] 8 Housemaid
[] 9 Other

403. Is [the respondent] male or female?

[] 1 Male
[] 2 Female

404. How old is [the respondent]? _ _

405. What is [the respondent's] marital status?

[] 1 Single
[] 2 Married
[] 3 Divorced
[] 4 Widowed

406. Does [the respondent] have a birth certificate from civil registration?
[Question 406 was asked of persons age 0 to 4.]

[] 1 Yes
[] 2 No

407. Does [the respondent] have an identity card?
[Question 407 was asked of persons age 17 or older or who have ever been married]

[] 1 Yes
[] 2 No

408. Was she ever married?
[Question 408 was asked of women who were age 10 or older.]

[] 1 Yes
[] 2 No

Check the corresponding box to assure that [everyone was counted in the questions in section IV.A. who should have been]:

1. Are there any other persons such as children or infants who have not been listed?

[] 1 Yes - write in the table [section IV.A., list of household members]
[] 2 No

2. Are there any people who are not your family members such as housemaids, lodgers, or friends who usually live here?

[] 1 Yes - write in the table [section IV.A., list of household members]
[] 2 No

3. Are there any guests or temporary visitors staying here for six months or more who have not been listed?

[] 1 Yes - write in the table [section IV.A., list of household members]
[] 2 No

4. Are there any other people who usually live here but have gone away for less than six months?

[] 1 Yes - write in the table [section IV.A., list of household members]
[] 2 No

5. Are there any people who have been listed as a member of household who have gone away for fewer than six months but intend to move?

[] 1 Yes - write in the table [section IV.A., list of household members]
[] 2 No

IV.B. Occurrence of deaths since January 2002

409. What is the name of the dead person? ____

410. What year did [the deceased] die? _ _

411. Sex of [the deceased]?

[] 1 Male
[] 2 Female

412. How old was [the deceased] when [he/she] died?

a) Younger than 2 years (age in months)
_ _ Month
b) Older than 2 years (age in years)
_ _ Year

413. What caused [the deceased] to die?

[] 1 Traffic accident
[] 2 Not a traffic accident
[] 3 Not an accident

414. Did the deceased die:
[Question 414 was asked of deceased women age 10 or older]

During pregnancy?
[] 1 Yes
[] 2 No
During delivery/miscarriage?
[] 1 Yes
[] 2 No
Postnatal period or within 2 months after childbearing/miscarriage?
[] 1 Yes
[] 2 No

V.A. Vital occurrence report

501. Does this household have a family card from current residence?

[] 1 Yes [go to Q.503]
[] 2 No

502. Does this household have a family card with other address?
[Question 502 was asked of household without a family card from the current residence, as per question 501.]

[] 1 Yes
[] 2 No

503. Has a birth occurred in this household within the last year?

[] 1 Yes
[] 2 No [go to Q.506]

504. Has the birth been reported to the village office?
[Question 504 was asked of households with a birth occurrence in the last year, as per question 503.]

[] 1 Yes
[] 2 Yes, partly
[] 3 No [go to Q.506]

505. Has the household received a birth statement letter from the village office for the birth reported?
[Question 505 was asked of households with a birth occurrence in the last year that has been reported to the village office, as per questions 503-504.]

[] 1 Yes
[] 2 Yes, partly
[] 3 No

506. Has a death occurred in this household within the last year?

[] 1 Yes
[] 2 No [go to Q.509]

507. Has the death been reported to the village office?
[Question 507 was asked of households with a death in the last year, as per question 506.]

[] 1 Yes
[] 2 Yes, partly
[] 3 No [go to Q.509]

508. Has the death report received a death statement letter from the village office?
[Question 508 was asked of households with a death in the last year that has been reported to the village office, as per questions 506-507.]

[] 1 Yes
[] 2 Yes, partly
[] 3 No

509. In the last year have there been any members or ex-members of this household who have moved to another village?

[] 1 Yes
[] 2 No [go to Q.512]

510. Has the location change been reported to the village office?
[Question 510 was asked of households with a member who moved in during the last year, as per question 509.]

[] 1 Yes
[] 2 Yes, partly
[] 3 No [go to Q.512]

511. If reported, has a statement letter from the village office been received for all location changes?
[Question 511 was asked of households with a member who moved during the last year that was reported to the village office, as per questions 509-510.]

[] 1 Yes [for all location changes]
[] 2 Yes, partly [for some, but not all, moves]
[] 3 No

512. In the last year, have there been any members or ex-members of this household who have moved into this village from another village?

[] 1 Yes
[] 2 No [go to Q.515]

513. Has the move-in been reported to the village office?
[Question 513 was asked of households with a member who moved in during the last year, as per question 512.]

[] 1 Yes
[] 2 Yes, partly
[] 3 No [go to Q.515]

514. If reported, has a statement letter, family card, or identity card been received for all moves-ins?
[Question 514 was asked of households with a member who moved in during the last year, which was reported to the village office, per questions 512-513.]

[] 1 Yes [for all location changes]
[] 2 Yes, partly [for some, but not all, moves]
[] 3 No

V.B. Housing conditions

515. What is the ownership of this dwelling unit?

[] 1 Self-owned
[] 2 Contract
[] 3 Rent
[] 4 Free
[] 5 Official
[] 6 Parent/relatives-owned
[] 96 Other (specify) ____

516. Primary construction material of roof.

[] 1 Concrete
[] 2 Wood
[] 3 Tile
[] 4 Asbestos/zinc
[] 5 Sugar palm fiber/leaves
[] 6 Other (specify) ____

517. Primary construction material of outer wall.

[] 1 Brick
[] 2 Wood
[] 3 Bamboo
[] 4 Other (specify) ____

518. Primary construction material of floor.

[] 1 Ceramic/marble/granite
[] 2 Tile
[] 3 Cement/brick
[] 4 Wood
[] 5 Bamboo
[] 6 Earth
[] 96 Other

519. Floor area

____ square meters _ _ _

520. What is the primary lighting in this dwelling unit?

[] 1 Electricity
[] 2 Gas
[] 3 Pump lamp
[] 4 Kerosene lamp
[] 6 Other (specify) ____

521. What is the primary cooking fuel used in this household?

[] 1 Electricity
[] 2 Gas
[] 3 Kerosene
[] 4 Coal
[] 5 Charcoal
[] 6 Wood
[] 96 Other (specify) ____

522. What is the primary source of drinking water for this household's members?

[] 1 Piped water [go to Q.524]
[] 2 Covered well
[] 3 Uncovered well
[] 4 Covered spring
[] 5 Uncovered spring [go to Q.524]
[] 6 River [go to Q.524]
[] 7 Lake/dam [go to Q.524]
[] 8 Rain water [go to Q.524]
[] 9 Bottled water [go to Q.524]
[] 96 Other (specify) ____ [go to Q.524]

523. How far is the distance between the well and the nearest cesspool?
[The questionnaire suggests that Question 523 was to be asked of those who answered "covered spring", but the census instructions and the data indicate they were not asked.]

____ meters _ _

524. Where do the household members take a bath?

[] 1 Private bathroom
[] 2 Shared bathroom
[] 3 Public bathroom
[] 6 Other (specify) ____

525. What kind of toilet facility does your household have?

[] 1 Private toilet with septic tank
[] 2 Private toilet with no septic tank
[] 3 Shared toilet
[] 4 Public toilet
[] 5 River
[] 6 Pit
[] 7 Yard/bush/forest
[] 96 Other (specify) ____

526. Do any of your household members own:

Car/truck
[] 1 Yes
[] 2 No
Motorcycle/motorboat
[] 3 Yes
[] 4 No
Bicycle/rowboat
[] 5 Yes
[] 6 No
Radio/tape/CD
[] 7 Yes
[] 8 No
Television
[] 9 Yes
[] 1 No
Telephone/hand phone
[] 2 Yes
[] 3 No
Refrigerator
[] 4 Yes
[] 5 No

Filled by supervisor

Check the corresponding box to assure block VI was already filled:

1. Are there age questions (Q.404 and Q.603) that have not yet been filled?

[] 1 Yes - write in the list
[] 2 No

2. For each household members, is the age recorded for Q.404 the same as for Q.603 ?

[] 1 Not yet - correct the answer
[] 2 Done

3. Are any household members for whom [questions] Q.601 - Q.610 have not yet been filled?

[] 1 Yes - write in the list
[] 2 No

4. Are there any household members age 5 or older for whom Q. 611 - Q.629 have not yet been filled?

[] 1 Yes - write in the list
[] 2 No

5. Are there any household members age 10 or older for whom Q. 626 - Q.629 have not yet been filled?

[] 1 Yes - write in the list
[] 2 No

6. Are there any household members age 60 or older for whom Q. 630 - Q.639 have not yet been filled?

[] 1 Yes - write in the list
[] 2 No

VI. Characteristics of individual household members

VI.A. Household members of all age
[Questions 601 - 610 were asked of all household members.]

601. Name: ____
No. household member _ _

602. When were you born?

Month _ _
Year _ _ _ _

603. Write age at the last birthday.

If month and year of birth is unknown, ask:

How old are you now?
Year _ _

604. What is your religion?

[] 1 Muslim
[] 2 Catholic
[] 3 Protestant
[] 4 Hindu
[] 5 Buddhist
[] 6 Confucian
[] 96 Other (specify) ____

605. What is your citizenship status?

[] 1 Indonesian [go to Q.606a]
[] 2 Foreigner [go to Q.606b]

606a. What is your ethnicity?
[Question 606a was asked of persons who answered "Indonesian" in question 605.]

(Specify) ____
Island/archipelago of ethnicity
[] 1 Sumatera
[] 3 Java
[] 5 Nusa Tenggara
[] 6 Kalimantan
[] 7 Sulawesi
[] 8 Maluku
[] 9 Papua
[] 0 Foreign
Filled by supervisor
Ethnicity group _ _
Ethnicity code _ _ _ _

606b. What is your citizenship?
[Question 606b was asked of persons who answered "Foreigner" in question 605.]

Specify ____
Filled by supervisor

_ _

607. Where were you born?

Province _ _
Regency/municipality _ _

608. Did you ever live in other regencies/municipalities?

[] 1 Yes
[] 2 No [if age is younger than 5, go to the next household member; if age is 5 or older, go to Q.616]

[Questions 609 - 615 were asked of persons who answered "Yes" in question 608.]

609. Where was your last residence before you lived in your current residence?

Province _ _
Regency/municipality _ _

610. How long have you lived in this current regency/municipality?

Years _ _

VI.B. Household members age 5 or older
[Questions 611 - 625 were asked of household members age 5 or older.]

611. Do you return to your hometown periodically?

[] 1 Yes
[] 2 No [go to Q.613]

612. How often do you return to your hometown?
[Question 612 was asked of persons who answered "Yes" in question 611.]

[] 1 At least once a week
[] 2 Once a month
[] 3 At least once in six months
[] 4 Seldom

613. [How long have you lived in this current regency/municipality?] (from Q.610)

[] 4 years or fewer
[] 5 years or more [go to Q.616]

[Questions 614 - 615 were asked of persons age 5 or older who have lived in the current regency/municipality for "4 years or fewer", as per question 613.]

614. Where did you live five years ago (June 2000)?

(Filled by supervisor)
Province _ _
Regency/municipality _ _

615. What was your main reason for moving from your residence five years ago?

[] 1 Occupation
[] 2 Looking for work
[] 3 Education
[] 4 Marital status change
[] 5 Following spouse/parent/children
[] 6 Following sibling/other relatives
[] 7 Housing
[] 8 Security
[] 96 Other (specify) ____

616. Did you ever or still attend school?

[] 1 Never/not yet attend school [go to Q. 620]
[] 2 Attending school
[] 3 Not attending school any more

[Questions 617 - 619 were asked of persons age 5 or older who are "Attending school" or "Not attending school any more", as per question 616.]

617. What is your completed highest level of education; or, what education level do you currently attend?

[] 1 Primary school
[] 2 Junior high school
[] 3 Senior high school
[] 4 Vocational senior high school
[] 5 Diploma I/II
[] 6 Diploma III/bachelor
[] 7 Diploma IV/undergraduate
[] 8 Postgraduate

618. What is your highest grade of attended/attending education? (Completed = 7)

619. What is your highest level of education attainment?

[] 1 None
[] 2 Primary school
[] 3 Junior high school
[] 4 Senior high school
[] 5 Vocational senior high school
[] 6 Diploma I/II
[] 7 Diploma III/bachelor
[] 8 Diploma IV/undergraduate
[] 9 Postgraduate

620. Are you able to read and write?

Latin letters?
[] 1 Yes
[] 2 No
Arabic letters?
[] 3 Yes
[] 4 No
Other letters (specify)?
____
[] 6 Yes
[] 5 No

621. Do you have activities such as working, attending school, taking courses, etc. in another regency/municipality and routinely travel daily to and from this house?

[] 1 Yes
[] 2 No [go to Q.626]

[Questions 622 - 625 were asked of persons age 5 or older who commute outside the regency, as per question 621.]

622. What is your primary activity there?

[] 1 Working
[] 2 Attending school
[] 3 Taking course
[] 6 Other (specify) ____

623. How far is the distance from your home to the place of activity?

Km _ _ _

624. How long does it take to get from your house to the place of activity?

Minutes _ _ _

625. What kind of transportation do you commonly use to and from the place of activity?

Public transportation
Going to
[] 1 Yes
[] 2 No
Coming home
[] 3 Yes
[] 4 No
Shared transportation
Going to
[] 5 Yes
[] 6 No
Coming home
[] 7 Yes
[] 8 No
Private transportation
Going to
[] 9 Yes
[] 1 No
Coming home
[] 2 Yes
[] 3 No
Without transportation
Going to
[] 4 Yes
[] 5 No
Coming home
[] 6 Yes
[] 7 No

VI.C. Household members age 10 or older
[Questions 626 - 629 were asked of household members age 10 or older.]

626.a. Did you work during the past week for at least one hour in order to earn money or goods?

[] 1 Yes [go to Q.627]
[] 2 No

626.b. Do you have work or business but temporarily you did not work during the past week?
[Question 626.b was asked of persons age 10 or older who did not work in the past week, as per question 626.a.]

[] 1 Yes
[] 2 No [if age is younger than 60 years, go to next household member; if age is 60 years or older, go to Q.630]

[Questions 627 - 629 were asked of persons age 10 or older who had work in the past week, as per question 626]

627. Main industry of your work.

Write completely: ________
Filled by CBS _ _ _

628. Classification of occupation of main work.

Write completely: ________
Filled by CBS _ _ _

629. Employment status of main work

[] 1 Own account worker
[] 2 Self employed assisted by temporary employee/unpaid employee
[] 3 Employer
[] 4 Regular employee
[] 5 Casual employee in agriculture
[] 6 Casual employee not in agriculture
[] 7 Unpaid worker

VI.D. Household member age 60 or older
[Questions 630 - 639 were asked of household members age 60 or older.]

630. In the last six months, did you receive money or goods from:

Work/business?
[] 1 Yes
[] 2 No
Retirement money [pension]/social security?
[] 3 Yes
[] 4 No
Interest/deposits?
[] 5 Yes
[] 6 No
Shares/bonds/securities?
[] 7 Yes
[] 8 No
Spouse?
[] 9 Yes
[] 1 No
Children/son or daughter in-law?
[] 2 Yes
[] 3 No
Relative/other family?
[] 4 Yes
[] 5 No
Other people?
[] 6 Yes
[] 7 No

631. See Q. 630, if there is at least one "Yes" circled, ask: Which is the largest source among them?
[Question 631 is asked of persons age 60 or older who received money from any source listed, as per question 630.]

Write the code of the largest source of money or goods [from question 630]

632. Is the income source enough to fulfill everyday necessities?

[] 1 Yes
[] 2 No

633. According to you, what is your health status?

[] 1 Good
[] 2 Enough
[] 3 Unfavorable

634. Do you need and use an appliance to assist [you medically]?

Eye glasses
Need
[] 1 Yes
[] 2 No
Use
[] 3 Yes
[] 4 No
Hearing aid
Need
[] 5 Yes
[] 6 Yes
Use
[] 7 Yes
[] 8 No
Walking aid
Need
[] 9 Yes
[] 1 No
Use
[] 2 Yes
[] 3 No

635. If there is any "Need, yes" as well as "Use, no" in Q.634, ask: What is your reason for not using it?
[Question 635 was asked of persons age 60 or older who answered to needing an aid but not using it for any section of question 634.]

Eye glasses
[] 1 Unable to buy
[] 2 Not available
[] 3 Other
Hearing aid
[] 4 Unable to buy
[] 5 Not available
[] 6 Other
Walking aid
[] 7 Unable to buy
[] 8 Not available
[] 9 Other

636. In daily activities, do you need other people's help for:

Dressing
[] 1 Yes
[] 2 No
Defecating/urinating
[] 3 Yes
[] 4 No
Bathing
[] 5 Yes
[] 6 No
Eating/drinking
[] 7 Yes
[] 8 No
Preparing food
[] 9 Yes
[] 1 No

637. See Q.636: if there is any "Yes" circled, ask: Who assists you in:
[Question 637 was asked of persons age 60 or older who answered to need help in any part of question 636.]

Dressing?
[] 1 Spouse
[] 2 Children
[] 3 Other family
[] 4 Other people
Defecating/urinating?
[] 1 Spouse
[] 2 Children
[] 3 Other family
[] 4 Other people
Bathing?
[] 1 Spouse
[] 2 Children
[] 3 Other family
[] 4 Other people
Eating/drinking?
[] 1 Spouse
[] 2 Children
[] 3 Other family
[] 4 Other people
Preparing food?
[] 1 Spouse
[] 2 Children
[] 3 Other family
[] 4 Other people

638. In the last six months, did you:

Watch television?
[] 1 Yes
[] 2 No
Read/write?
[] 3 Yes
[] 4 No
Went on vacation/travel?
[] 5 Yes
[] 6 No
Play sport?
[] 7 Yes
[] 8 No
[Engage in] social activities?
[] 9 Yes
[] 1 No
Go fishing?
[] 2 Yes
[] 3 No
[Maintain a] garden or aquarium?
[] 4 Yes
[] 5 No

639. During the past month, which was your main [hobby]?

Write the code of the main hobby [from question 638]

VII. Ever married women age 10 or older
[Questions 701 - 723 were asked of women age 10 or older who have ever been married.]

VII.A. Marriage

701. Name: ____
No. of household member _ _

702. In what month and year was your first marriage?

Month _ _
Year _ _ _ _

703. How old were you at your first marriage?

Year _ _

704. How many times have you been married?

Times _ _

705. How long have you been married?

Years _ _

706. See Q.405 (respondent's current marital status)

[] 1 Married
[] 2 Divorced [or] widowed [go to Q.708]
707. Is your husband a part of the household?
[Question 707 was asked of married women age 10 or older, as per question 706.]

[] 1 Yes
No. of husband _ _ [go to Q.709]
[] 2 No [go to Q.709]

708. How long have you lived without a husband?
[Question 708 was asked of divorced/widowed women age 10 or older, as per question 706.]

Years _ _

VII.B. Family planning

709. Have you ever used family planning methods?

[] 1 Yes
[] 2 No [go to Q.717]

[Questions 710 - 711 were asked of women who have ever used family planning methods, as per question 709.]

710. What was your last family planning method?

[] 1 Female sterilization
[] 2 Male sterilization
[] 3 Pill
[] 4 IUD
[] 5 Injection, 1 month
[] 6 Injection, 3 months
[] 7 Implant, 3 years
[] 8 Implant, 5 years
[] 9 Condom
[] 10 Intra-vaginal/diaphragm
[] 11 Lactational amenorrhea method
[] 12 Periodic abstinence
[] 13 Withdrawal
[] 96 Other (specify) ____

711. See Q.405 (respondent's marital status)

[] 1 Married
[] 2 Divorced [or] widowed [go to Q.718]

712. Are you currently using any family planning method?
[Question 712 was asked of married women age 10 or older who have ever used family planning methods, as per questions 709 and 711.]

[] 1 Yes
[] 2 No [go to Q.717]

713. What method are you using?
[Question 713 was asked of married women age 10 or older currently using family planning, as per questions 711 and 712.]

[] 1 Female sterilization
[] 2 Male sterilization
[] 3 Pill
[] 4 IUD
[] 5 Injection, 1 month
[] 6 Injection, 3 months
[] 7 Implant, 3 years
[] 8 Implant, 5 years
[] 9 Condom
[] 10 Intra-vaginal/diaphragm
[] 11 Lactational amenorrhea method [go to Q.718]
[] 12 Periodic abstinence [go to Q.718]
[] 13 Withdrawal [go to Q.718]
[] 96 Other (specify) ____ [go to Q.718]

[Questions 714-716 were asked of married women currently using the family planning methods of "Female sterilization", "Male sterilization", "Pill", "IUD", "Injection, 1 month", "Injection, 3 months", "Implant, 3 years", "Implant, 5 years", "Condoms", or "Intra-vaginal/diaphragm", as per questions 711-713.]

714. Where did you obtain the method the last time you used it?

Public Sector
[] 11 Hospital
[] 12 Village health clinic [puskesmas/pustu]
[] 13 Clinic
[] 14 Fieldworker [PLKB]
[] 15 Mobile unit [TKBK/TMK]
[] 16 Other (specify) ____
Private medical center
[] 21 Hospital
[] 22 Clinic
[] 23 Doctor
[] 24 Village midwife
[] 25 Pharmacy/drug store
Other
[] 31 Polindes
[] 32 Health post [KB/PPKBD]
[] 33 P.P. post [IHC]
[] 34 Friend/relative
[] 35 Shop
[] 36 Other (specify) ____

[] 98 Don't know

715. When was the last time you used a family planning method?

Month _ _
Year _ _ _ _

716. Last time you used a family planning service, did you have to pay for it?

[] 1 Yes
[] 2 No [go to Q.718]

717. What is your primary reason for not using a family planning method?

[Question 717 was asked of women not currently using family planning methods, as per questions 709 and 712.]

Fertility related reason
[] 11 Not having/infrequent sex
[] 12 Menopause/hysterectomy
[] 13 Sub-fecundity/infecundity
[] 14 Wants as many children as possible
Opposition to use
[] 21 Respondent opposed
[] 22 Husband opposed
[] 23 Other person opposed
[] 24 Religious prohibition
Lack of knowledge
[] 31 Knows no method
[] 32 Knows no source
Method related reason
[] 41 Health concern
[] 42 Fear of side effects
[] 43 Too far
[] 44 Cost too much
[] 45 Inconvenient
[] 46 Gain/loss weight
[] 96 Other (specify) _____
[] 98 Don't know

VII.C. Fertility

718. Have you ever given birth?

[] 1 Yes
[] 2 No [go to Q.736]

719. How old were you at your first delivery?
[Questions 719 - 735 were asked of women who answered "Yes" in question 718.]

____ Year _ _

720. How many sons and daughters to whom you have given birth live with you?

_ _ Sons
_ _ Daughters

721. How many sons and daughters to whom you have given birth are alive but do not live with you?

_ _ Sons
_ _ Daughters

722. How many sons and daughters to whom you have given birth were alive but later died?

_ _ Sons
_ _ Daughters

723. Total number of sons and daughters

_ _

VII.D. Birth history of children
[Questions 724 - 735 were asked of every woman who ever delivered a baby]

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

725. Were any of these births twins?

[] 1 Single
[] 2 Multiple

726. Is [the child] a boy or a girl?

[] 1 Boy
[] 2 Girl

727. In what month and year was [the child] born?

Probe: When was his/her last birthday?
Month _ _
Year _ _ _ _

728. Who assisted with the delivery of [the child]?

[] 1 Doctor
[] 2 Midwife
[] 4 Traditional birth attendant
[] 8 Other _ _

729. Is [the child] still alive?

[] 1 Yes
[] 2 No [go to Q.732]

730. If alive, how old was [the child] at his/her last birthday?
[Questions 730 - 731 were asked of women who answered "Yes" in question 729.]

Age in years _ _

731. If alive, is [the child] living with you?

[] 1 Yes [go to Q. 733]
[] 2 No [go to Q. 733]

732. If dead, how old was [the child] when he/she died?
[Question 732 was asked of women who answered "No" in question 729.]

If "1 year" [is the answer given], probe: how many months old was (name)? Record [age] in days if younger than 1 month; in months, if younger than two years; or in years, if two years or older. If younger than 1 day, record "00" in days.

[] 1 Days _ _
[] 2 Months _ _
[] 3 Years _ _

733. Were there any other live births between [the previous birth] and [this child]?
[Only applicable for second or further birth records]

[] 1 Yes
[] 2 No

734. Have you had any live births since the birth of (name of last birth)?
[Question 734 was asked only if the last child referenced in question 724 was age 4 or older]
Subtract the year of the interview from the birth year of the last child. If [the child is] 4 years or older, ask [this question]:

[] 1 Yes
[] 2 No

735. Was your husband with you when you delivered your last child?

[] 1 Yes
[] 2 No

Filled by supervisor

Give check sign in corresponding box.

1. Is Q. 603 relevant to Q. 703, Q.705, Q.708 and Q.719?

[] 1 Not yet - correct the record
[] 2 Done

2. If Q.718 = 1, are Q.719 - Q.723 relevant?

[] 1 Not yet - correct the record
[] 2 Done

3. If Q.718 = 1, is the last line of Q.724 relevant to Q.733?

[] 1 Not yet - correct the record
[] 2 Done

4. If Q.729 = 1 is the child name already listed in Q.401?

[] 1 Not yet - correct the record
[] 2 Done

5. Do the number of filled lines in Q.737 equal the number of total daughters in Q.736?

[] 1 Not yet - correct the record
[] 2 Done

6. Are Q.739 - Q.743 relevant?

[] 1 Not yet - correct the record
[] 2 Done

VII.E. List of female siblings
[Questions 736 - 743 were asked of all persons.]

736. How many children did your mother deliver?

_ _ Male
_ _ Female
_ _ Total

737. What are your sisters' names? ____

Write [beginning] from the oldest

738. Is she still alive?

[] 1 Yes [go to next sister record]
[] 2 No
[] 8 Don't know [go to next sister record]

739. When did she die?
[Questions 739 - 743 were asked of persons who listed the name in 737 as "No" [not alive] in question 738.]

Year _ _ _ _

740. How old was she when she died?

_ _ [If she died before she was 10 years old, go to next sister record]

741. Was she pregnant when she died, or did she die during childbearing?
[Questions 741 - 743 were asked of persons who listed an age of 10 and older when they died for the name listed in question 737.]

[] 1 Yes [go to Q.743]
[] 2 No

742. Did she die within 42 days after the end of pregnancy?
[Question 742 was asked of persons who answered "No" in question 741 for the name listed in 737.]

[] 1 Yes
[] 2 No [go to next sister record]

743. Did she die due to complication of pregnancy, delivery or postnatal period?
[Question 743 was asked of persons who answered "Yes" in question 741 or "Yes" in question 742 for the name listed in 737.]

[] 1 Yes
[] 2 No