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Demographic and Health Survey 2009-10 - Timor-Leste Ministry of ...

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374 | Appendix E<br />

INTRODUCTION AND CONSENT<br />

INFORMED CONSENT<br />

SECTION 1. RESPONDENT'S BACKGROUND<br />

Hello. My name is _______________________________________ <strong>and</strong> I am working with NATIONAL STATISTICS<br />

DIRECTORATE.We are conducting a national survey that asks men <strong>and</strong> women about various health issues. We would very<br />

much appreciate your participation in this survey. This information will help the government to plan health services. The survey<br />

usually takes about 20 minutes to complete. Whatever information you provide will be kept strictly confidential <strong>and</strong> will<br />

not be shared with anyone other than members <strong>of</strong> our survey team.<br />

Participation in this survey is voluntary, <strong>and</strong> if we should come to any question you don't want to answer, just let me know <strong>and</strong><br />

I will go on to the next question; or you can stop the interview at any time. However, we hope that you will participate in this survey<br />

since your views are important.<br />

At this time, do you want to ask me anything about the survey?<br />

May I begin the interview now?<br />

Signature <strong>of</strong> interviewer: Date:<br />

RESPONDENT AGREES TO BE INTERVIEWED . . . . . 1 RESPONDENT DOES NOT AGREE TO BE INTERVIEWED . . . 2 END<br />

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

<strong>10</strong>1 RECORD THE TIME.<br />

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

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

<strong>10</strong>2 How long have you been living continuously in (NAME OF<br />

CURRENT PLACE OF RESIDENCE)? YEARS . . . . . . . . . . . . . . . . . .<br />

IF LESS THAN ONE YEAR, RECORD '00' YEARS. ALWAYS . . . . . . . . . . . . . . . . . . . . . . 95<br />

VISITOR . . . . . . . . . . . . . . . . . . . . . . 96 <strong>10</strong>6<br />

<strong>10</strong>3 Just before you moved here, did you live in a city, in a town, or in CITY . . . . . . . . . . . . . . . . . . . . . . . . . . . 1<br />

the countryside? TOWN . . . . . . . . . . . . . . . . . . . . . . . . . . . 2<br />

COUNTRYSIDE . . . . . . . . . . . . . . . . . . 3<br />

<strong>10</strong>6 In what month <strong>and</strong> year were you born?<br />

<strong>10</strong>7 How old were you at your last birthday?<br />

COMPARE AND CORRECT <strong>10</strong>6 AND/OR <strong>10</strong>7 IF INCONSISTENT.<br />

MONTH . . . . . . . . . . . . . . . . . .<br />

DON'T KNOW MONTH . . . . . . . . . . . . 98<br />

YEAR . . . . . . . . . . . .<br />

DON'T KNOW YEAR . . . . . . . . . . . . 9998<br />

AGE IN COMPLETED YEARS<br />

<strong>10</strong>8 Have you ever attended school? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1<br />

NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 112<br />

<strong>10</strong>9 What is the highest level <strong>of</strong> school you attended: PRIMARY . . . . . . . . . . . . . . . . . . . . . . 1<br />

primary, pre-secondary, secondary or higher? PRE-SECONDARY . . . . . . . . . . . . . . 2<br />

SECONDARY . . . . . . . . . . . . . . . . . . . . 3<br />

HIGHER . . . . . . . . . . . . . . . . . . . . . . . . 4<br />

1<strong>10</strong> What is the highest (grade) you completed at that<br />

level? GRADE . . . . . . . . . . . . . . . . . .

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