SN | QUESTIONS | ANSWERS | CODE | NO |
1 | Sex | 1) Male 2) Female | 01 02 | [ ] |
2 | Age | [ ] |
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3 | Are you a studying? | 1) Yes 2) No If yes which class are you? ----------If no which class have you ended --- and what are you doing? ----------------------------- | 01 02
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4 | Have you had sex? | 1) Yes 2) No If yes at what age you initiated sex? --------------------------------- | 01 02
| [ ] |
5 | Have you heard about ASRHS? | 1) Yes 2) No | 01 02 | [ ] |
6 | Which of the following ASRHS ever utilized by you? | 1) Information and counseling on RHS 2) HIV counseling & testing 3) Testing &Treated for STI symptoms 4) Contraceptives 5) None Other specify------------------------ | 01 02 03 04 05
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7 | In addition to the above question which among the following ASRHS ever sought on counselling/utilized the services? | 1) Antenatal care 2) STI prevention 3) Postnatal care 4) Post abortion care 5) Emergency contraceptives 6) None | 01 02 03 04 05 06 | [ ] |
8 | Where do you get the ASRHS service from? | 1) Government health facility 2) Private health facility 3) Pharmacy 4) School 5) Special groups/counselors 6) No where Other specify------------------------ | 01 02 03 04 05 06
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9 | Are the health facilities located near a place where adolescents live? | 1) Yes 2) No 3) I don’t know | 01 02 03 | [ ] |
10 | Is the health facilities open during hours that are convenient for adolescents? | 1) Yes 2) No 3) I don’t know | 01 02 03 | [ ] |
11 | Are SRH services offered for free for adolescents? | 1) Yes 2) No 3) I don’t know | 01 02 03 | [ ] |
12 | Do health workers providers ensure privacy and confidentiality for adolescents? | 1) Yes 2) No 3) I don’t | 01 02 03 | [ ] |