Age

Village

Caste

Do you go to school?

SOURCE OF INFO

1. What is your most important source for finding out about menstruation?
[choose one]

Mother

Sister

Sister-in-law

Friends

School Teacher

ASHA worker

Taruni Sakhi/Prerak

ANM

Do not know

Other (specify) _____

2. Have you ever told any of your friends about what you learned in school about
menstruation?

Yes

No

Haven’t learned about menstruation

KNOWLEDGE

3. Do you know the biology behind menstruation? (use terms: bachhadani,

andashe, ande)
Yes

No

4. Do you know how to use a pad?

Yes

No

5. Do you know about methods used for preventing pregnancy?

Yes

No

5. a. If yes, how?

Mother

Sister

Sister-in-law

Friends

School Teacher

ASHA worker

Taruni Sakhi/Prerak

Others ____

6. Do you know why menstruation is important for being able to conceive

children?

Yes

No

7. Please list all the hygiene (saaf safai) practices you use during menstruation?
[choose multiple]
Bathing daily

Washing private parts multiple times during the day

Changing pads twice/thrice during the day

Keeping the “toilet” area dry and clean

Others (specify) _____

8. How do you dispose of pads? [choose multiple]

Burn

Bury under rock

Dig a pit and cover with soil

I don’t use pads

Other (specify) _____

8. a. Is the disposal of pads difficult?

Yes

No

I don’t use pads

ATTITUDES/PERCEPTION

Do you consider periods “important” or “not important”? (HOW TO

UNDERSTAND IF THEY SEE NEGATIVELY OR POSITIVELY)?

Important

Not Important

9. Rate the following statements out of

Strongly Agree
Agree
Neutral
Disagree
Strongly Disagree

a. Women should not go to the temple during their periods

b. Women should not touch pickle during their periods
c. It is okay to have a boyfriend before marriage

10. When do you think girls should get married (at what age)?

Below 18

18-20

20-22

22-24

After 24

PRACTICES/AVENUES TO REACH OUT

11. Have you ever paid money to buy pads?

Yes

No

I don’t use pads

12. How many times have you used cloth during your periods?

1-2 times

2-3 times

3-4 times

More than 4 times

Never

12. a. If used, could you explain why? ____

13. Have you ever not attended school because of period related problems?
Yes

No

14. Have you ever faced any medical problem from using cloth or pads during
periods? [Choose Multiple]

Rashes

Itching

Skin Problems

None

Others _____

15. What issues related to periods cause stress/worry you? (tension hoti hai)
[choose multiple]

Delay in periods

Irregular periods

Very short/very long periods (2-3 days or 8-9 days)

Absence of period for 1-2 months

Very heavy flow

Very light flow

None

Others ____

16. If any selected, whom do you go to when you face these problems? [Choose
Multiple]

Mother

Sister

Sister-in-law

Friends
School Teacher

ASHA worker

Taruni Sakhi/Prerak

ANM

Internet

Bengali Doctor

Public Hospital

Private Hospital

No One

Others ____

16. a. If no one, why do you not reach out to anyone? [choose multiple]

Shyness

Male members in household

Nobody talks about it

Will be blamed for any problem/issue in their bodies

Will be suspected of having affair/doing something wrong

Others _____

17. Who are you comfortable speaking about your periods to? [choose multiple]

Mother

Sister

Sister-in-law

Friends

School Teacher
ASHA worker

Taruni Sakhi/Prerak

ANM

Doctor (hospital)

No one

WATER

18. Do you fetch water for your household?

Yes

No

18a. If yes, where do you fetch it from?

Well

Handpump

River

Tanker

Have water connection in house

Others ____

18b. How much time in a day do you spend on fetching water?

0 – 15 minutes

15 – 30 minutes

30 – 45 minutes

45 minutes and above

PHONE USAGE
19. Do you own a WhatsApp phone?

Yes

No

19. a. If no, does anyone in your family own a WhatsApp phone that you open
WhatsApp on?

Yes

No

20. How frequently do you use WhatsApp? [select one]

1-2 times a day

More than 2 times a day

On need basis (use on someone’s phone when needed)

Never

21. What do you use WhatsApp for? [choose multiple]

Information/knowledge

WhatsApp groups

Talking to friends

Sending photos

Sending videos/music

Others: _____