QUESTIONNAIRE

Sl. No. Question Code Response

1. What is your age? Actual response ---
2. In which class you are? Actual response ---
3. Residential Address ? Actual response ---
4. Educational qualification of your father Actual response ---
5. Occupation of your father Actual response ---
6. Educational qualification of your mother Actual response ---
7. Occupation of your mother Actual response ---
8. Type of family 1. ---
Nuclear
2. Joint
3. Three
generation

*
Nuclear – It is a family where in a married couple and their children while they
are still regarded as dependants line in the same dwelling space ; lating from the
same kitchen.

*
Joint – It is a family that consist of a number of married couples and their
children who line together in the same household and wherein the men are
related by blood and the women of the household are their wives, unmarried
girls & windows of the family kinsmen. See the property is held in common with
the authority unsted is senior male member of the family. They al lat from the
** same kitchen.

Three generation – It is a family wherein one can find the representatives of

three generations and their families but lating from separate kitchen. They occur
as young couples after fail to find their own separate accommodation & continue
to line will their parents & have their own children.
Sl. No. Question Code Response
1. Age of starting of periods & Actual Response ---
menstruation
2. What is menstruation periods 1 –
Normal Process ---
2 –
Abnormal Process
3 –
A disease
3. Why do you think period/mens 1 –
cleans body of dirty blood. ---
occurs 2 –
Female becomes capable
of child bearing
3 – Sign of attaining physical
maturity
4 – Don’t know.
4. What was your reaction when Actual Process ---
you had your first periods?
5. Do you follow any ritual or 1 – Yes ---
restriction during periods?
6. What type of ritual or restriction 1 – Entering kitchen & temple ---
you follow? 2 – Touching utensils
3 – Traveling & Playing outside
4 – Others (specify)
7. Do you think these rituals & 0 – No ---
restrictions are right? 1 – Yes
8. What type cleanliness / do you 1 – cloth that is reusable after ---
precautionary wash
2 – Sanitary pads.
3 – Others (specify)
9. How often do you change clothe 1 – Once a Days ---
or sanitary pads during periods? 2 – Twice a Day
3 – Thrill a Day
10. What is the source information 1 – Mother ---
for you regarding periods? 2 – Elder Sister
3 – Friends
4 – Teachers
5 – Books & Magazine
6 – TV and Radio
7 – Others (specify)
11. How is your period? 1 – Regular ---
2 – Irregular
12. Is your period accompanied with 1 – Pain ---
any of these ? 2 – Heavy bleeding
3 – Scanty bleeding
4 – Others (specify)

* Regular Period – If your period comes after a find period of time is 28 Days /
30 Days / 32 Days (whatever is applicable) always.
Irregular period – If the period doesn’t complete a fined cycle is sometimes it
comes after 28 Days and in same other time after 32 Days or even longer.

Sl. No. Question Code Response

13. Do you feel any of these 1 – Low back pain ---
symptoms before periods? 2 – Heaviness in breast
3 – Premenstrual tension
14. How do you feel after you 1 – Weakness ---
period is over? 2 – Sense of relief.
3 – Others (specify)
15. Some physical change occur in 1 – Voice change ---
the body before/after period 2 – Hair in the armpit
what kind of physical change 3 – Breast budding
occur? 4 – Growth of pulses hair
16. What are the organ/organs of 1 – Uterus ---
reproduction in a females body? 2 – Ovaries
3 – Vainer
17. What is the duration of normal Actual Response
pregnancy

* Premenstrual tension – Is a condition where is a female often has mood

swings, may remain irritable, may complain of headache etc.

Sl. No. Question Code Response

18. What is sex education Actual Response ---
19. What is the appropriate age for Actual Response ---
sex education in school?
20. Who will be the appropriate 1 – Mother / Parents ---
reason for sex education? 2 – Friends
3 – Teachers
4 – Doctor
5 – Others (specify)
21. Are you aware of any methods 0 – No ---
to avoid delays pregnancy? 1 – Yes
22. If yes, what are these methods? 1 – Female sterilization ---
2 – Male sterilization
3 – Oral pills
4 – Copper – T
5 – Condom
6 – Periodic abstinence
7 – Withdrawal
8 – Others (specify)
23. Have you ever seen any of the 0 – No ; 1 – Yes ---
following? 0 – No ; 1 – Yes
0 – No ; 1 – Yes

* Periodic abstinence – To avoid sexual intercourse during the ovulation period

i.e. 8th to the 22nd day of menstrual cycle, counting from the first day of the
menstrual cycle.
Sl. No. Question Code Response
24. From where you can get these? 1 – Medical store ---
2 – Doctor
3 – Nurse
4 – Health workers
5 – others (specify)
25. What is the source of 1 – Mother ---
information regarding 2 – Elder sister
contraceptive methods? 3 – Relative
4 – Teacher
5 – Newspaper/Magazine/Books
6 – Media / TV / Radio
7 – Health worker
8 – Others (specify)
26. Have you ever used any 0 – No ---
medicine to postpone or delay 1 – Yes
your periods?
27. If Yes, from where you have got 1 – Mother ---
such medicine (pill) 2 – Sister
3 – Friends
4 – Medical shop
5 – Doctor
6 – Health workers
7 – Others (Specify)
28. If gives a choice, where would 1 – Co-education school ---
you went to study? 2 – Girls only school
29. Do you have a boyfriend? 0 – No ---
1 – Yes
30. If No, would you like to make 0 – No
one? 1 – Yes
31. Do you know what is the
appropriate age for marriage?

Boys ----- Actual Response

Girls ------ Actual Response
 KNOWLEDGE, ATTITUDE & PREVENTION REGARDING SEXUALLY

Sl. No. Question Code Response

32. Have you ever hearer about 0 – No ---
STDs? 1 – Yes
33. If you then, what are the types? 1 – Hepatitis A ---
2 – AIDS
3 – Syphilis
4 – Symphograns ****
5 – Malaria
6 – Trichomoniosis
7 – TB
8 - Gonorrhoer
9 – Otehrs (specify)
34. What are the features of STD? 1 – Pain in the lower abdomen ---
2 – Foul smelling discharge
from private parts
3 – Itching sens action &
blisters in private parts
4 – Fever
5 – Genital ***
6 – Burning ***
7 – Peaceful defecation
8 – Reduces of skin
9 – Others (specify)
35. Have you ever suffered from 0 – No ---
only of the features of STD as 1 – Yes
maintained?
36. Have you ever heard about 0 – No ---
AIDS 1 – Yes
37. What are the modes of 1 – Sex ---
transmission of HIV/AIDS? 2 – Mother to bailey
3 – Syringes
4 – Blood transfusion
5 – Kissing
6 – Hugging
7 – Shaking hands
8 – Others (specify)
38. What are the preventive steps Actual Response ---
for HIV/AIDS.
39. What are the source of 1 – Parents ---
information regarding STDs & 2 – Friends
HIV/AIDS 3 – Relatives
4 – Teacher
5 – Media
6 – Poster & Hoardings
7 – Health worker
8 – Others (specify)
40 Do you share your knowledge 0 – No
 regarding STDs & AIDS with 1 – Yes
others?
41. What are the preventive steps Open ** ---
you STDs? Actual Response
42. Do you think you need specific 0 – No ---
information regarding STDs & 1 – Yes
AIDS.
43. How do you updates your Actual Response
knowledge regarding
reproduction, contraception &
STDs