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DEMOGRAPHIC AND HEALTH SURVEY - BANGLADESH 2004 - HOUSEHOLD QUESTIONNAIRE (ENGLISH)

BANGLADESH

IDENTIFICATION

DIVISION:

DISTRICT:

UPAZILA:

UNION OR WARD:

VILLAGE OR MOHALLA OR BLOCK:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

RURAL OR MUNICIPALITY OR OTHER URBAN OR SMA?

RURAL 1
MUNICIPALITY 2
OTHER URBAN 3
SMA 4

IS HOUSEHOLD IN A SLUM?

YES 1
NO 2

NAME OF THE SLUM:

NAME OF HOUSEHOLD HEAD:

IS 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 OF TIME
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
YEAR
INTERVIEWER’S CODE
RESULT*

TOTAL NUMBER OF VISITS:

TOTAL PERSONS IN HOUSEHOLD:

TOTAL ELIGIBLE WOMEN:

TOTAL ELIGIBLE MEN:

LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE:

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR

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 guests of the household who stayed here last night, starting with the head of the household.

___

1. Are there any other persons such as small children or infants that we have not listed?

YES (ENTER EACH IN TABLE)
NO

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

YES (ENTER EACH IN TABLE)
NO

3. Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

YES (ENTER EACH IN TABLE)
NO

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

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

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

MALE 1
FEMALE 2

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

YES 1
NO 2

6. Did (NAME) stay here last night?

YES 1
NO 2

7. AGE: How old is (NAME)?

IF AGE IS LESS THAN 1 YEAR, WRITE ‘00’.

AGE IN YEARS ___

MARITAL STATUS IF AGED 10 OR ABOVE

8. What is the current marital status of (NAME)?

CURRENTLY MARRIED 1
FORMERLY MARRIED (DIVORCED OR WIDOWED OR SEPARATED OR DESERTED) 2
NEVER MARRIED 3

ELIGIBILITY

9. CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN AGE 10-49 (CODE 1 OR 2 IN QUESTION 8)

10. IF HOUSEHOLD CHOSEN FOR MEN’S SURVEY, CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

11. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER 6.

12. RECORD MOTHER’S LINE NUMBER OF ALL CHILDREN UNDER 6.

RECORD ‘00’ IF MOTHER OF CHILDREN NOT LISTED IN HOUSEHOLD.

___

EDUCATION IF AGE 5 YEARS OR OLDER

16. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 19)

17. What is the highest level of schooling (NAME) has last attended? What is the highest class (NAME) completed at that schooling?

LEVEL
PRIMARY 1
SECONDARY 2
COLLEGE AND HIGHER 3
GRADE
LESS THAN 1 YEAR COMPLETED 00
DON’T KNOW 98

EMPLOYMENT IF AGE 8 YEARS OR OLDER

19. Is (NAME) currently working?

YES 1
NO 2 (GO TO NEXT LINE)

20. Does (NAME) receive wages or income in cash or in kind?

CASH 1
KIND 2
BOTH 3
NONE 4

21. What is the main source of water your household used for dishwashing?

PROBE IF TUBE WELL IN MENTIONED.

PIPED WATER
PIPED INSIDE DWELLING 11
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SHALLOW TUBE WELL 22
DEEP TUBE WELL 23
SURFACE WELL OR OTHER WELL 24
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41
OTHER (SPECIFY) 96

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

PROBE IF TUBE WELL IS MENTIONED.

PIPED WATER
PIPED INSIDE DWELLING 11
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SHALLOW TUBE WELL 22
DEEP TUBE WELL 23
SURFACE WELL OR OTHER WELL 24
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41
OTHER (SPECIFY) 96

WILL YOU PLEASE GIVE ME SOME DRINKING WATER.

INTERVIEWER: PLEASE PRESERVES THE DRINKING WATER FOR ARSENIC TEST.

23. What is the source of this drinking water?

PROBE IF TUBE WELL IS MENTIONED.

PIPED WATER
PIPED INSIDE DWELLING 11
PIPED OUTSIDE DWELLING 12
WELL WATER
TUBE WELL 21
SHALLOW TUBE WELL 22
DEEP TUBE WELL 23
SURFACE WELL OR OTHER WELL 24
SURFACE WATER
POND OR TANK OR LAKE 31
RIVER OR STREAM 32
RAINWATER 41
OTHER (SPECIFY) 96

24. How long have you been using this source for drinking water?

YEARS ___

25. Have you heard or arsenic?

YES 1
NO 2

26. CHECK QUESTION 23: CIRCLED ‘21’ OR ‘22’ OR ‘23’

YES (GO TO 27)
NO (GO TO 29)

27. Is the tube well marked red or green color from where you obtained this water for drinking?

RED 1
GREED 2 (GO TO 28B)
UNMARKED 3 (GO TO 29)
DON’T KNOW 8 (GO TO 29)

28A. Do you know the meaning of red color in the tube well?

ARSENIC IN THE WATER A (GO TO 29)
NOT SAFE TO DRINK B (GO TO 29)
OTHER (SPECIFY) X (GO TO 29)
DON’T KNOW Z (GO TO 29)

28B. Do you know the meaning of green color in the tube well?

NOT ARSENIC IN THE WATER A
SAFE TO DRINK B
OTHER (SPECIFY) X
DON’T KNOW Z

29. 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

31. Does your household (or any member of your household) have:

Electricity?
YES 1
NO 2
Almirah or wardrobe?
YES 1
NO 2
A table?
YES 1
NO 2
A 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
A motorcycle?
YES 1
NO 2
A sewing machine?
YES 1
NO 2
Telephone or mobile phone?
YES 1
NO 2

32. MAIN MATERIAL OF THE ROOF.

RECORD OBSERVATION.

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

33. 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

34. 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

35. Besides bathroom, how many rooms are there in your household?

ROOMS ___

36. How many rooms do you have for sleeping?

SLEEPING ROOMS ___

38. What type of fuel does your household mainly use for cooking?

WOOD 01
CROP RESIDUE OR GRASS 02
DUNG CAKES 03
COAL OR COKE OR LIGNITE 04
CHARCOAL 05
KEROSENE 06
ELECTRICITY 07
LIQUID GAS OR GAS 08
BIO-GAS 09
OTHER (SPECIFY) 96

39. What type of cooking stove is mainly used in your house?

KEROSINE STOVE 1
GAS STOVE 2
OPEN FIRE 3
OPEN FIRE OR STOVE WITH CHIMNEY OR HOOD 4
CLOSED STOVE WITH CHIMNEY 5
OTHER (SPECIFY) 6

40. Where is cooking usually done?

IN A ROOM USED FOR LIVING OR SLEEPING 1
IN A SEPARATE ROOM IN SAME BUILDING USED AS KITCHEN 2
IN A SEPARATE BUILDING USED AS KITCHEN 3
OUTDOORS 4
OTHER (SPECIFY) 6

41. Does your household own any homestead?

IF ‘NO’, PROBE: Does our household own homestead any other places?

YES 1
NO 2

42. Does your household own any land (other than the homestead land)?

YES 1
NO 2 (GO TO 44)

43. How much land does your household own (other than the homestead land)?

AMOUNT ___
ACRES ___
DECIMALS ___
SPECIFY UNIT ___

44. In terms of household food consumption, how do you classify your household: deficit in whole year; sometimes deficit; neither deficit nor surplus; surplus.

DEFICIT IN WHOLE YEAR 1
SOMETIMES DEFICIT 2
NEITHER DEFICIT NOT SURPLUS 3
SURPLUS 4

44A. USE ARSENIC TEST KIT TO TEST DRINKING WATER AND CIRCLED APPROPRIATE CODE.

0 01
10 02
10-25 03
25 04
25-50 05
50 06
50-100 07
100 08
100-250 09
250 10
250-500 11
500-1500 12
1500-4000 13
OTHER (SPECIFY) 96

44B. IS THERE ANY SMELL OF ROTTEN EGG IN THE DRINKING WATER THAT WAS COLLECTED FOR TESTING?

YES 1
NO 2

HEIGHT AND WEIGHT MEASUREMENT

CHECK COLUMNS 9 AND 11: RECORD THE LINE NUMBER, NAME AND AGE OF ALL EVER MARRIED WOMEN AGE 10-29 AND ALL CHILDREN UNDER 6 YEARS.

45. LINE NUMBER

FOR WOMEN 10-49 FROM COLUMN 9 ___
FOR CHILDREN UNDER 6 FROM COLUMN 11 ___

46. NAME

FOR WOMEN 10-49 FROM COLUMN 2 ___
FOR CHILDREN UNDER 6 FROM COLUMN 2 ___

47. AGE

FOR WOMEN 10-49 FROM COLUMN 7 ___
FOR CHILDREN UNDER 6 FROM COLUMN 7 ___

48. What is (NAME)’s date of birth?

(ASK ONLY FOR CHILDREN UNDER 6 YEARS)

DAY ___
MONTH ___
YEAR ___

49. WEIGHT IN KILOGRAMS

WOMEN 10-49 ___
CHILDREN UNDER 6 ___

50 HEIGHT IN CENTIMETERS

WOMEN 10-49 ___
CHILDREN UNDER 6 ___

51. MEASURED LYING DOW OR STANDING UP

(ASK ONLY FOR CHILDREN UNDER 6 YEARS)

LYING 1
STANDING 2

51. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER