Date | |__|__|/|__||__|/|__||__| DD MM YY | ||
Telephone number | |__|__|__|/|__|__|/|__|__|/|__|__| |__|__|__|/|__|__|/|__|__|/|__|__| | ||
1. Sociodemographic characteristics | |||
Age | |__||__| | ||
Marital status | 1. single 2. cohabiting 3. married | |__|__| | |
Occupation | 1. Unemployed 2. Employed | |__|__| | |
Educational level | 1.uneducated 2. primary education 3. secondary education 4. university | |__|__| | |
How many times have you been pregnant | |__|__| | ||
How many children do you have | |__|__| | ||
HIV status | 1. positive 2. negative 3. I don’t know | |__|__| | |
2. Assessing gender-based violence | |||
2.1. Physical violence | |||
Have you been slapped or thrown at something that can hurt you? | 1. Yes 2. No | |__|__| | |
Have you been pushed or shoved? | 1. Yes 2. No | |__|__| | |
Have you been hit with a fist or something else that could hurt? | 1. Yes 2. No | |__|__| | |
Have you been kicked? | 1. Yes 2. No | |__|__| | |
Have you been dragged or beaten up? | 1. Yes 2. No | |__|__| | |
Have you been choked or burnt on purpose? | 1. Yes 2. No | |__|__| | |
Have you had a gun, knife or other weapons used against you? | 1. Yes 2. No | |__|__| | |
2.2. Sexual violence | |||
Have you be physically forced to have sexual intercourse against your will? | 1. Yes 2. No | |__|__| | |
Have you had sexual intercourse because you are afraid of what your partner might do? | 1. Yes 2. No | |__|__| | |