Date

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DD MM YY

Telephone number

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1. Sociodemographic characteristics

Age

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Marital status

1. single

2. cohabiting

3. married

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Occupation

1. Unemployed

2. Employed

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Educational level

1.uneducated

2. primary education

3. secondary education

4. university

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How many times have you been pregnant

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How many children do you have

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HIV status

1. positive

2. negative

3. I don’t know

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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

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Have you been pushed or shoved?

1. Yes

2. No

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Have you been hit with a fist or something else that could hurt?

1. Yes

2. No

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Have you been kicked?

1. Yes

2. No

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Have you been dragged or beaten up?

1. Yes

2. No

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Have you been choked or burnt on purpose?

1. Yes

2. No

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Have you had a gun, knife or other weapons used against you?

1. Yes

2. No

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2.2. Sexual violence

Have you be physically forced to have sexual intercourse against your will?

1. Yes

2. No

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Have you had sexual intercourse because you are afraid of what your partner might do?

1. Yes

2. No

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