Coversheet

1 STAHA FACILITY EXIT QUESTIONNAIRE COVERSHEET Interviewer Name District 1 Korogwe 2 Muheza Facility name 1 Magunga Hospital 2 Teule Hospital ID number (district code + interviewer code + respondent code) Interview date & starting time (AUTOMATIC STAMP) Interview ending time (AUTOMATIC STAMP) INTRODUCTION “Hello my name is...and I am working with Ifakara Health Institute and Columbia University in the United States. The reason I am here is because we are conducting a survey on health in Tanga region and I would like to ask a few questions of women who have given birth in this health care facility. I will be asking for basic information about yourself, your household, and your health. I will also ask questions about your use of health care in general and about your experiences with child delivery. Let me assure you that whatever information is give to me will not be shared with anyone and will only be used for research purposes.”