DEMOGRAPHIC AND HEALTH SURVEYS
DISABILITY MODULE
MODEL HOUSEHOLD QUESTIONNAIRE
PLACE NAME __________
NAME OF HOUSEHOLD HEAD __________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
NAME AND LINE NUMBER OF WOMAN __________
HOUSEHOLD SELECTED FOR MAN'S SURVEY (1=YES, 2=NO)
(1) This section should be adapted for country-specific survey design.
FIRST VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
SECOND VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
THIRD VISIT:
DATE ______
INTERVIEWER'S NAME ________
RESULT* ________
NEXT VISIT:
DATE ______
TIME ______
FINAL VISIT:
DAY __ __
MONTH __ __
YEAR __ __ __ __
INT. NO. __ __ __ __
RESULT* __
TOTAL NUMBER OF VISITS: __
*RESULT CODES:
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AND HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) __________
TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW** __ __
NATIVE LANGUAGE OF RESPONDENT** __ __
TRANSLATOR USED (YES = 1, NO = 2)
LANGUAGE OF QUESTIONNAIRE** ENGLISH
**LANGUAGE CODES
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
SUPERVISOR
NAME ______
NUMBER __ __ __ __
FIELD EDITOR
NAME ______
NUMBER __ __ __ __
OFFICE EDITOR
NUMBER __ __
KEYED BY
NUMBER __ __
Note: Brackets [] indicate items that should be adapted on a country-specific basis.
IF AGE 5 OR OLDER
26. DISABLITY: Does (NAME) wear glasses or contact lenses to help them see?
NO 2 (GO TO 28)
27. I would like to know if (NAME) has difficulty seeing even when wearing glasses or contact lenses. Would you say that (NAME) has no difficulty seeing, some difficulty, a lot of difficulty, or cannot see at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8
(GO TO 29)
28. I would like to know if (NAME) has difficulty seeing. Would you say that (NAME) has no difficulty seeing, some difficulty, a lot of difficulty, or cannot see at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8
29. Does (NAME) wear a hearing aid? (1)
NO 2 (GO TO 31)
(1) This question may be excluded in countries where wearing a hearing aid is not common.
30. I would like to know if (NAME) has difficulty hearing even when using a hearing aid. Would you say that (NAME) has no difficulty hearing, some difficulty, a lot of difficulty, or cannot hear at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT HEAR AT ALL 4
DON'T KNOW 8
31. I would like to know if (NAME) has difficulty hearing. Would you say that (NAME) has no difficulty hearing, some difficulty, a lot of difficulty, or cannot hear at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT HEAR AT ALL 4
DON'T KNOW 8
32. I would like to know if (NAME) has difficulty communicating when using his/her usual language. Would you say that (NAME) has no difficulty understanding or being understood, some difficulty, a lot of difficulty, or cannot communicate at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT COMMUNICATE AT ALL 4
DON'T KNOW 8
33. I would like to know if (NAME) has difficulty remembering or concentrating. Would you say that (NAME) has no difficulty remembering or concentrating, some difficulty, a lot of difficulty, or cannot remember or concentrate at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT REMEMBER/CONCENTRATE AT ALL 4
DON'T KNOW 8
34. I would like to know if (NAME) has difficulty walking or climbing steps. Would you say that (NAME) has no difficulty walking or climbing steps, some difficulty, a lot of difficulty, or cannot walk or climb steps at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT WALK OR CLIMB AT ALL 4
DON'T KNOW 8
35. I would like to know if (NAME) has difficulty washing all over or dressing. Would you say that (NAME) has no difficulty washing all over or dressing, some difficulty, a lot of difficulty, or cannot wash all over or dress at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT WASH OR DRESS AT ALL 4
DON'T KNOW 8