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DEMOGRAPHIC AND HEALTH SURVEY - BANGLADESH 1996-97 - HOUSEHOLD QUESTIONNAIRE (ENGLISH)

BANGLADESH

IDENTIFICATION

DIVISION:
DISTRICT:
THANA:
UNION OR WARD:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:

DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE?

1 DHAKA OR CHITTAGONG
2 SMALL CITY
3 TOWN
4 VILLAGE

NAME OF HOUSEHOLD HEAD:
IS THE HOUSEHOLD SELECTED FOR MEN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT
DATE INTERVIEWER'S NAME
RESULT*

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH

01 JANUARY
02 FEBRUARY
03 MARCH
04 APRIL
05 MAY
06 JUNE
07 JULY
08 AUGUST
09 SEPTEMBER
10 OCTOBER
11 NOVEMBER
12 DECEMBER

YEAR 199_
CODE
RESULT

TOTAL NUMBER OF VISITS
TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN

LINE NUMBER OF RESPONDED TO HOUSEHOLD SCHEDULE

NAME
DATE

FIELD EDITED BY

OFFICE EDITED BY

KEYED BY

KEYED BY

HOUSEHOLD SCHEDULE
Now we would like some information about the people who usually live in your household or who are staying with you now.

1. LINE NUMBER:

___

2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guest of the household who stayed here last night, starting with the head of the household?

___

3. RELATIONSHIP TO HEAD HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

01 HEAD
02 WIFE
03 SON OR DAUGHTER
04 SON OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED OR FOSTER CHILD
11 NOT RELATED
98 DOES NOT KNOW

Just to make sure that I have a complete listing:
4. Are there any other persons such as small children or infants that we have not listed?

YES (ENTER EACH IN TABLE)
NO

5. In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?

YES (ENTER EACH IN TABLE)
NO

6. Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?

YES (ENTER EACH IN TABLE)
NO

7. RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

8. Did (NAME) sleep here last night?

YES 1
NO 2

9. SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

10. AGE: How old is (NAME)?

IN YEARS ___

EDUCATION IF AGED 6 YEARS OR OLDER
11. Has (NAME) ever been to school?

YES 1
NO 2

IF ATTENDED SCHOOL
12. What is the highest level of school (NAME) attended? What is the highest class (NAME) completed at that level?

LEVEL OF EDUCATION
1 PRIMARY
2 SECONDARY
3 COLLEGE OR UNIVERSITY
8 DOES NOT KNOW
CLASS
00 LESS THAN ONE YEAR COMPLETED
98 DOES NOT KNOW

IF AGED LESS THAN 25 YEARS

13. Is (NAME) still in school?

YES 1
NO 2

MARITAL STATUS FOR ALL AGED 10 YEARS OR ABOVE
14. Has (NAME) ever been married?

YES 1
NO 2

15. WOMEN ELIGIBILITY: CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN AGE 10-49.

16. HUSBAND' LINE NUMBER: WRITE THE LINE NUMBER OF THE HUSBAND OF THOSE IN (15).

IF NOT MARRIED OR IF HUSBAND NOT IN HOUSEHOLD, WRITE '00'.

17. MAN'S ELIGIBILITY: IF HOUSEHOLD CHOSEN FOR MEN'S SURVEY, CIRCLE LINE NUMBER OF ALL EVER MARRIED MEN AGE 15-59.

18. What is the source of water your household uses for dishwashing?

PIPED WATER
PIPED INSIDE DWELLING 11
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SURFACE WELL OR OTHER WELL 22
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41
OTHER (SPECIFY) 96

19. What is the source of drinking water for members of your household?

PIPED WATER
PIPED INSIDE DWELLING 11
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SURFACE WELL OR OTHER WELL 22
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41
OTHER (SPECIFY) 96

20. What kind of toilet facility does your household have?

SEPTIC TANK OR MODERN TOILET 11
PIT TOILET OR LATRINE
WATER SEALED OR SLAB LATRINE 21
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
NO FACILITY OR BUSH OR FIELD 31
OTHER (SPECIFY) 96

21. Where do adult women in your household usually defecate?

SEPTIC TANK OR MODERN TOILET 11
PIT TOILET OR LATRINE
WATER SEALED OR SLAB LATRINE 21
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
NO FACILITY OR BUSH OR FIELD 31
OTHER (SPECIFY) 96

22. Where do children in your household usually defecate?

SEPTIC TANK OR MODERN TOILET 11
PIT TOILET OR LATRINE
WATER SEALED OR SLAB LATRINE 21
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
NO FACILITY OR BUSH OR FIELD 31
OTHER (SPECIFY) 96
NO CHILDREN 97

23. Does your household have electricity?

YES 1
NO 2

24. Does your household have:

Almirah?
YES 1
NO 2
A table, chair, or bench?
YES 1
NO 2
A watch or clock?
YES 1
NO 2
A cot or bed?
YES 1
NO 2
A radio that is working?
YES 1
NO 2
A television that is working?
YES 1
NO 2
A bicycle?
YES 1
NO 2

25. Does any member of your household own agricultural land?

YES 1
NO 2

26. In the last 2 weeks, has anyone in your household been to any health facility or been to see a doctor or nurse for any reason?

YES 1
NO 2 (GO TO 29)

27. Where did he or she go?

PUBLIC SECTOR
HOSPITAL OR MEDICAL COLLEGE 11
FAMILY WELFARE CENTRE 12
THANA HEALTH COMPLEX 13
SATELLITE OR EPI CLINIC 14
MEDICAL PRIVATE SECTOR
PRIVATE CLINIC OR DOCTOR 21
TRADITIONAL DOCTOR 22
PHARMACY 23
OTHER PRIVATE SECTOR
SHOP 32
FRIENDS OR RELATIVES 32
FIELDWORKER, FWA 41
OTHER (SPECIFY) 96
DOES NOT KNOW 98

28. What was the reason for the visit?

PREVENTIVE SERVICES
IMMUNIZATION 11
FAMILY PLANNING 12
ANTENATAL CHECKUP 13
CURATIVE SERVICES
ILLNESS 21
ACCIDENT 22
OTHER (SPECIFY) 96

29. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOF
KATCHA (BAMBOO OR THATCH) 11
RUDIMENTARY ROOF
TIN 21
FINISHED ROOF
CEMENT OR CONCRETE 31
OTHER (SPECIFY) 96

30. MAIN MATERIAL OF THE WALLS.

RECORD OBSERVATION.

NATURAL WALLS
JUTE OR BAMBOO OR MUD (KATCHA) 11
RUDIMENTARY WALLS
WOOD 21
FINISHED WALLS
BRICK OR CEMENT 31
TIN 32
OTHER (SPECIFY) 96

31. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
EARTH OR BAMBOO (KATCHA) 11
RUDIMENTARY FLOOR
WOOD 21
FINISHED FLOOR (PUKKA)
CEMENT OR CONCRETE 31
OTHER (SPECIFY) 96

32. IS THIS HOUSEHOLD IN A BOSTI (SLUM)?

RECORD OBSERVATION.

YES 1
NO 2