SN

QUESTIONS

ANSWERS

CODE

NO

1

Sex

1) Male

2) Female

01

02

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2

Age

[ ]

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

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5

Have you heard about ASRHS?

1) Yes

2) No

01

02

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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

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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------------------------

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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

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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

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11

Are SRH services offered for free for adolescents?

1) Yes

2) No

3) I don’t know

01

02

03

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12

Do health workers providers ensure privacy and confidentiality for adolescents?

1) Yes

2) No

3) I don’t

01

02

03

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