| No | QUESTIONS | CODE |
| 01 | Have you ever been pregnant? 1. Yes; 2. No if yes, go to question 03 | |__| |
| 02 | If no, would you like to have a child before 19? 1. Yes; 2. No; 3. indecise Go to section III | |__| |
| 03 | How many times have you ever been pregnant? ………… | | __|__| |
| 04 | How old were you at the time of your pregnancy (s)? ………………………… | | __|__| |
| 05 | How old was your partner (the author of your pregnancy) when you conceived the first pregnancy? ............... | | __|__| |
| 06 | Was your first pregnancy: 1. Desired; 2. Planned; 3. Accidental 4. Rape | | __| |
| 07 | How did you confirm this pregnancy? 1. By the signs (morning sickness/vomiting, breast tension/pain, increased frequency of urine, etc.); 2. Test at home; 3. Test at the hospital; 4. Announced by an acquaintance. | | __| |
| 08 | Who was the perpetrator of your pregnancy (s)? 1. Pupil at your school; 2. Pupil from another school; 3. Student; 4. Teacher from your school; 5. Member of your family (specify ………..…); 6. Your husband; 7. Unknown; 8. Other (specify ……………………………………). | |__|__| |
| 09 | What has become of this (these) pregnancy (s)? (specify the outcome for each pregnancy): 1. Childbirth; 2. Spontaneous abortion; 3. Voluntary abortion | |__||__||__| |
| 10 | If case of voluntary abortion, what were the reasons? 1. Fear of reaction from parents/guardians; 2. Fear of being expelled from school; 3. Fear of the burden that the child will place on you in the future; 4. Fear of dropping out of school; 5. Fear of the reaction and judgment of others; 6. Other reasons (to be specified) …………………………………………………… | |__|__| |