| No | QUESTIONS | CODE |
| 01 | Do you know about family planning services? 1. Yes; 2. No If no, go to S7Q04 | |__|__| |
| 02 | If so, have you already consulted them? 1. Yes; 2. No If yes, go to S7Q04 | |__|__| |
| 03 | If not why? 1. Distance; 2. Fear of cost; 3. Useless; 4. Others (to be specified) …………………………………. | |__| |
| 04 | Do you have anything to add? ..........................................................………….....…………………………………………… ……………………………………………….…………………………………………………………………………………………………………………………………………………………………………………………………………………… | |__|__| |