NIPORT, MOHFW, Mitra and Associates

IDENTIFICATION

DIVISION____
DISTRICT____
UPAZILA____
UNION/WARD____
VILLAGE/MOHALLA/BLOCK____
CLUSTER NUMBER____
HOUSEHOLD NUMBER____
RURAL, MUNISIPALITY, OTHER URBAN, OR SMA:

HOUSEHOLD IN A SLUM?

NAME OF THE SLUM____
NAME OF THE HOUSEHOLD HEAD____
HOUSEHOLD SELECTED FOR MEN'S SURVEY?

INTERVIEWER VISITS

FIRST VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

NEXT VISIT:
DATE____
TIME____

SECOND VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

NEXT VISIT:
DATE____
TIME____

THIRD VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

FINAL VISIT:
DAY____
MONTH____
YEAR: 2007
INT. NUMBER____
RESULT:

TOTAL NUMBER OF VISITS____

TOTAL PERSONS IN HOUSEHOLD____
TOTAL ELIGIBLE WOMEN____
TOTAL ELIGIBLE MEN____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

SUPERVISOR
NAME____
DATE____

FIELD EDITOR
NAME____
DATE____

OFFICE EDITOR____
KEYED BY____

INTRODUCTION AND CONSENT

Hello. My name is ____ and I am working with Mitra and Associates, a private research organization located in Dhaka. To assist in the implementation of socio-development programs in the country, we conduct different types of surveys. We are now conducting a national survey about the health of women, men and children under the authority of NIPORT of Ministry of Health and Family Welfare. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete.
As part of the survey we would first like to ask some questions avout your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to any question you don't want to answer, just let me know and I will go on to the next question; or you can stop the interview at any time. However, we hope you will participate in the survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
Signature of interviewer: ____
Date: ____

HOUSEHOLD SCHEDULE

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.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A TO 2C TO BE SURE THAT THE LISTING IS THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5 THROUGH 15 FOR EACH PERSON.

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

4) SEX
Is (NAME) male or female?

RESIDENCE
5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE
How old is (NAME)? IF AGE LESS THAN 1 YEAR WRITE '00'.

8) IF AGE 10 OR OLDER
MARITAL STATUS
What is (NAME'S) current marital status?

ELIGIBILITY
9) CIRCLE LINE NUMBER OF ALL EVER-MARRIED WOMEN AGE 10 TO 49
(QUESTION 8 IS 1 OR 2) PUT A STAR FOR THE LINE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE

10) CIRCLE LINE NUMBER OF ALL EVER MARRIED MEN AGE 15 TO 54
(QUESTION 8 IS 1 OR 2) PUT A STAR FOR THE LINE NUMBER OF THE MAN SELECTED FOR THE DOMESTIC VIOLENCE

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0 TO 5

IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL
12) Has (NAME) ever attended school?

13) What is the level of schooling (NAME) has last attended? SEE CODES BELOW. What is the highest class (NAME) completed at that level? SEE CODES BELOW.

14) IF AGE 5 TO 24 YEARS
CURRENT SCHOOL ATTENDANCE
Is (NAME) currently attending school?

15) IF AGE 8 OR OLDER
CURRENT WORK STATUS
Is (NAME) currently working?

TICK HERE IF CONTINUATION SHEET USED____

2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

HOUSEHOLD CHARACTERISTICS

101) What is the main source of drinking water for members of your household?

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

104) Do you do anything to the water to make it safer to drink?

105) What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED.

106) What kind of toilet facility do members of your household use?

107) Do you share this toilet facility with other households?

108) How many households use this toilet facility?

109) Does your household have:

110) What type of fuel does your household mainly use for cooking?

111) What type of cooking stove is mainly used in your house?

113) Where is cooking usually done?

115) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

116) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

117) MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

118) How many rooms in this household are used for sleeping?

119) Does this household own any livestock, herds, other farm animals, or poultry?

120) How many of the following animals does this household own?
IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'.
Cows or bulls or buffalos?
Goats or sheep?
Chickens or ducks?

121) Does your household own any homestead? IF 'NO' PROBE: Does your household own homestead in any other places?

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

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

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0 TO 5

501) CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0 TO 5 YEARS IN QUESTION 502. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 508.

502) LINE NUMBER FORM COLUMN 11
NAME FROM COLUMN 2

503) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

504) CHECK 503: CHILD BORN IN JANUARY 2002 OR LATER?

505) WEIGHT IN KILOGRAMS

506) HEIGHT IN CENTIMETERS

507) MEASURED LYING DOWN OR STANDING UP?

508) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

509) CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 510. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

510) LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

511) WEIGHT IN KILOGRAMS

512) HEIGHT IN CENTIMETERS

513) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE FEMALE AND MALE RESPONDENTS ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. FOR EACH NON-ZERO NUMBER, THIS IS THE COLUMN YOU SHOULD GO TO. THE CELL WHERE THE ROW AND THE COLUMN MEET IS THE NUMBER OF THE SELECTED WOMAN OR MAN FOR THE DOMESTIC VIOLENCE MODULE.

FOR EXAMPLE, IF THE HOUSEHOLD NUMBER IS '216', GO TO ROW '6'. IF THERE ARE THREE ELIGIBLE WOMEN AGE 10 TO 49 IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE BOX ('2'). NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW. WRITE HER LINE NUMBER BELOW IN THE BOXES INDICATED. DO THE SAME FOR THE MEN.