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PDF, 1536K - Measure DHS

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NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP<br />

1109 For how long have you had a sexual relationship with this man?<br />

DAYS ......................................1<br />

WEEKS ...................................2<br />

MONTHS ................................3<br />

YEARS....................................4<br />

1110 Altogether, with how many different men have you had sex in the last<br />

12 months? NUMBER OF PARTNERS.........................<br />

1111 Do you know of a place where one can get condoms? YES.......................................................... 1<br />

NO............................................................ 2 1114<br />

1112 Where is that?<br />

IF SOURCE IS HOSPITAL, HEALTH CENTER, OR CLINIC, WRITE<br />

THE NAME AND/OR LOCATION OF THE PLACE. PROBE TO<br />

IDENTIFY THE TYPE OF SOURCE AND CIRCLE THE<br />

APPROPRIATE CODE.<br />

______________________________________________________<br />

(NAME AND/OR LOCATION OF PLACE)<br />

GOVERNMENT<br />

HOSPITAL ...........................................11<br />

HEALTH CENTER ...............................12<br />

HEALTH STATION/CLINIC .................13<br />

HEALTH POST ....................................14<br />

COMMUNITY-BASED OUTLET ..........15<br />

OTHER GOVERNMENT __________ 16<br />

(SPECIFY)<br />

NONGOVERNMENTAL (NGO)<br />

HEALTH FACILITY ..............................21<br />

COMMUNITY-BASED OUTLETS........22<br />

OTHER NGO ___________________ 26<br />

(SPECIFY)<br />

PRIVATE MEDICAL<br />

PRIVATE HOSPITAL...........................31<br />

PRIVATE DOCTOR .............................32<br />

PHARMACY.........................................33<br />

OTHER PRIVATE<br />

MEDICAL 36<br />

(SPECIFY)<br />

OTHER SOURCE<br />

DRUG VENDOR ..................................41<br />

SHOP...................................................42<br />

FRIEND/RELATIVE .............................43<br />

OTHER 46<br />

(SPECIFY)<br />

1113 If you wanted to, could you yourself get a condom? YES.......................................................... 1<br />

NO............................................................ 2<br />

DON’T KNOW/UNSURE.......................... 8<br />

1114 RECORD THE TIME.<br />

MORNING = 1<br />

EVENING = 2<br />

MORNING/EVENING ..................................<br />

HOUR ..........................................................<br />

MINUTES ....................................................<br />

THANK YOU

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