001a. Your name: ${your_name}

Is this your name?

001b. Enter your name below.

Please record your name

002a. Current date and time.

Is this date and time correct?

002b. Record the correct date and time.

The date must be between 2019-09-01 and 2020-09-01.

003a. County

003b. District (sub-county)

003c. Division

003d. Location

004. Enumeration area

005. Facility number

Please record the number of the facility from the listing form.

Must be larger than 0

006. Type of facility

Please select the type of facility.

007. Managing authority

Please select the managing authority for the facility.

008. Is a competent respondent present and available to be interviewed today?

INFORMED CONSENT

Find the competent female respondent. Administer the consent procedures.

009a. Provide a paper copy of the Consent Form to the respondent and read it.

Then, ask:
May I begin the interview now?

009b. Respondent's signature

Please ask the respondent to sign or check the box in agreement of their participation.

009c. Respondent?s name

Enter the respondent?s full name.

010. Interviewer's name: ${your_name}

Mark your name as a witness to the consent process.

011. Name of the facility

Please select the name of the facility.

011. Name of the facility

Please record the name of the facility.

SECTION 1 ? Background Information

I would like to start by asking a few questions about yourself.

100. Did you receive any family planning information or a method during your visit today?

If no, thank her for her time and end the interview.

101. How old were you at your last birthday?

Age must be less than 130.

102. Are you currently married or living together with a man as if married?

Probe: If no, ask whether the respondent is divorced, separated, or widowed.

103. What is the highest level of school you attended?

Only record formal schooling. Do not record bible or koranic school or short courses.

104. How many times have you given birth?

Enter 0 if she has never given birth.
Enter -99 for no response.

Please enter number less than 36.

105. Imagine a 10-step ladder where on the bottom, the first step, stand the poorest people, and on the highest step, the 10th, stand the rich. On which step is your household located today?

106. Is this the closest health facility to your current residence?

107. What was the main reason you did not go to the facility nearest to your home?

108. How much time did it take you to travel here today?
Minutes
Hours
Enter -88 for do not know in both, -99 for no response in both.

109. What means of transportation did you use to travel here?

If multiple means used PROBE: What was the primary mode of transportation?

LCL_101. Do you have any health insurance or are you a member of a mutual health organization?

LCL_102. What type of health insurance do you have?
You cannot select 'No response' with other options

SECTION 2 ? Family Planning Services

Now I would like to ask about family planning services you received today.

200. Was family planning the main reason you came here today?

201. What was the main reason for your visit today?

202. During your visit today, were you given a family planning method, a prescription for a method, or neither?

203. Did your provider discuss family planning with you today?

204. Which method(s) were you prescribed or given?

LCL_200. PROBE: Was the injection administered via syringe or small needle?

Show the image to the respondent.

LCL_201. Which methods were you counselled on during this visit today?
Select all methods mentioned. Be sure to scroll to bottom to see all choices.
You cannot select 'No response' with other options

205. Just before this visit, were you using the same method, did you switch from another method or were you using no method?

206. How long have you been using this method without stopping?

206. Enter a value for ${method_duration_lab}:

207. Have you ever used this method before?

208. Have you used it in the past 12 months?

209. During your visit today, did you obtain the method of family planning you wanted?

210. Which method did you initially want to use?

211. Why didn't you obtain the method you wanted?

212. Who made the final decision about what method you got today?

213. Did you pay any money for any of the family planning services you received or were provided today?

LCL_202. Was any of the money you paid today for family planning covered by insurance or some other health scheme?

214. Did the provider tell you that if you do not take the pill every day, your chances of becoming pregnant are higher?

215. Did the provider tell you that if you are more than one month late for your shot, your chances of becoming pregnant are higher?

216. During your visit today, for the method you were prescribed or given, did the provider:

a. Explain how to use the method?

216. During your visit today, for the method you were prescribed or given, did the provider:

b. Talk about possible side effects?

216. During your visit today, for the method you were prescribed or given, did the provider:

c. Tell you what to do if you have problems?

216. During your visit today, for the method you were prescribed or given, did the provider:

d. Tell you when to return for follow-up?

217. During your visit today, did the provider:

a. Tell you about contraceptive methods other than the method you were given or prescribed?

217. During your visit today, did the provider:

b. Talk about the methods that protect against HIV/AIDs and STIs?

217. During your visit today, did the provider:

c. Ask about your family planning method preference?

217. During your visit today, did the provider:

d. Tell you that you could switch to a different method in the future?

218. How clear was the family planning information you received today?

219. Did the provider allow you to ask questions?

220. Did the provider answer all your questions in a way you understood?

221. During your visit today, were you told by the provider about advantages and disadvantages with a method to delay or avoid pregnancy?

222. What advantages did the provider tell you about your ${method_prescribed_lab}?
You cannot select 'No response' with other options

223. What disadvantages did the provider tell you about your ${method_prescribed_lab}?

You cannot select 'No response' with other options

SECTION 3: Client Satisfaction
Now I would like to ask about the services you received today.

300. How long did you wait between the time you arrived at this facility and the time you were able to see a provider for the consultation?
Minutes

Enter time in minutes.
Enter -88 for do not know, -99 for no response.

Hours
Enter time in hours.
Enter -88 for do not know, -99 for no response.

Enter -88 for do not know in both, -99 for no response in both.

301. During this visit did the provider and other staff treat you very politely, politely, neither politely nor impolitely, impolitely, or very impolitely?

302. Overall, how satisfied are you with the family planning services you received at this establishment today? Would you say very satisfied, satisfied, neither satisfied nor dissatisfied, dissatisfied, or very dissatisfied?

303. Would you refer your relative or friend to this facility?

304. Would you return to this facility?

Follow-up Consent

FLW_801. Thank you for the time you have kindly granted us.

Could we contact you via phone to ask you questions to update this information in the next four months?

FLW_802. Do you own a phone?

FLW_803. Can I have your primary phone number in case we would like to follow up with you in the future?

Enter an 10-digit number without the country code. Do not include spaces or dashes.
Enter 0 for no response.

Invalid number of digits.

FLW_804. Can you repeat the number again?

Enter an 10-digit number without the country code. Do not include spaces or dashes.
Enter 0 for no response.

Number entered must match previously entered number.

FLW_805. May I have a secondary phone number to follow up with you in the future?

Enter an 10-digit number without the country code. Do not include spaces or dashes.
Enter 0 for no response.

Invalid number of digits.

FLW_806. Can you repeat the number again?

Enter an 10-digit number without the country code. Do not include spaces or dashes.
Enter 0 for no response.

Number entered must match previously entered number.

Thank the respondent for her time.

The respondent is finished, but there are still more questions for you to complete.

Thank you.

There are still more questions for you to complete.

QUESTIONNAIRE RESULT

098. In what language was this interview conducted?

099. Record the result of the Client Exit Interview Questionnaire.