National Research on Domestic Violence Against Women in

Annex 3. Questionnaire 2008 GEORGIA SURVEY ON WOMAN’S HEALTH AND LIFE EXPERIENCES IDENTIFICATION COUNTRY CODE REGION LOCATION (CAPITAL/TOWN = 1, PROVINCE = 2) WARD/VILLAGE ...................................................................................... CLUSTER NUMBER .................................................................................. HOUSEHOLD NUMBER ........................................................................... ____ [ ][ ] [ ] [ ][ ][ ] [ ][ ][ ] [ ][ ] NAME OF HOUSEHOLD HEAD : _______________________ INTERVIEWER VISITS 1 2 3 FINAL VISIT DATE ___________ ___________ ___________ DAY [ ][ ] MONTH [ ][ ] YEAR [ ][ ][ ][ ] INTERVIE ___________ ___________ ___________ INTERVIEWER [ ][ ] WERS ___________ ___________ ___________ RESULT [ ][ ] NAME RESULT*** NEXT VISIT: DATE ___________ ___________ ___________ ___________ ___________ ___________ TOTAL NUMBER OF VISITS [ ] TIME LOCATION QUESTIONNAIRES COMPLETED? [ ] 1. None completed ⇒ [ ] 2. HH questionnaire only ⇒ *** RESULT CODES Refused (specify): _________________ ________________________________... 11 Dwelling vacant or address not a dwelling12 Dwelling destroyed................................... 13 Dwelling not found, not accessible........... 14 Entire hh absent for extended period ...... 15 No hh member at home at time of visit ... 16 Hh respondent postponed interview ....... 17 Entire hh speaking only strange language. 18 Selected woman refused (specify): ____ ________________________________... 21 No eligible woman in household .............. 22 Selected woman not at home .................. 23 Selected woman postponed interview..... 24 Selected woman incapacitated ................ 25 ⇒Need to return ⇒Need to return ⇒Need to return ⇒Need to return CHECK HH SELECTION FORM: TOTAL IN HOUSEHOLD (Q1) [ ][ ] TOTAL ELIGIBLE WOMEN IN HH OF SELECTED WOMAN (Q3, total with YES) [ ][ ] LINE NUMBER OF SELECTED FEMALE RESPONDENT (Q3) [ ][ ] 98