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BANGLADESH DEMOGRAPHIC AND HEATH SURVEY 2007
HOUSEHOLD QUESTIONNAIRE

NIPORT, MOHFW, Mitra and Associates

IDENTIFICATION

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

RURAL 1
MUNICIPALITY 2
OTHER URBAN 3
SMA 4

HOUSEHOLD IN A SLUM?

YES 1
NO 2

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

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

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

NEXT VISIT:
DATE____
TIME____

SECOND VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

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

NEXT VISIT:
DATE____
TIME____

THIRD VISIT:
DATE____
INTERVIEWER'S NAME____
RESULT:

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

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

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

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: ____

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

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.

NAME____

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

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON IN LAW OR DAUGHTER IN LAW 04
GRANDCHILD 05
PARENT 06
PARENT IN LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98

4) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE
5) 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 LESS THAN 1 YEAR WRITE '00'.

AGE IN YEARS____

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

CURRENTLY MARRIED 1
DIVORCED/SEPARATED/DESERTED/WIDOWED 2
NEVER-MARRIED 3

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?

YES 1
NO 2 (GO TO 15)

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.

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

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

YES 1
NO 2

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

YES 1
NO 2

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?

YES (ADD TO TABLE)
NO

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?

YES (ADD TO TABLE)
NO

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

YES (ADD TO TABLE)
NO

HOUSEHOLD CHARACTERISTICS

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 104)
PIPED TO YARD/PLOT 12 (GO TO 104)
PUBLIC TAP/STANDPIPE 13 (GO TO 104)
TUBE WELL OR BOREHOLE 21 (GO TO 104)
DUG WELL
PROTECTED WELL 31 (GO TO 104)
UNPROTECTED WELL 32 (GO TO 104)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 104)
UNPROTECTED SPRING 42 (GO TO 104)
RAINWATER 51 (GO TO 104)
TANKER TRUCK 61 (GO TO 104)
CART WITH SMALL TANK 71 (GO TO 104)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 104)
BOTTLED WATER 91 (GO TO 104)
OTHER (SPECIFY)____ 96 (GO TO 104)

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

PIPED WATER
PIPED INTO DWELLING 11
PIPED TO YARD/PLOT 12
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLD 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER (SPECIFY)____ 96

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

YES 1
NO 2 (GO TO 106)
DON'T KNOW 8 (GO TO 106)

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

BOIL A
ADD BLEACH/CHLORINE/USE PURIFY TABLET B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
LET IT STAND AND SETTLE E
OTHER (SPECIFY)____ X
DON'T KNOW Z

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 31
HANGING TOILET/HANGING LATRINE 41
NO FACILITY/BUSH/FIELD 51 (GO TO 109)
OTHER (SPECIFY)____ 96

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

YES 1
NO 2 (GO TO 109)

108) How many households use this toilet facility?

NUMBER OF HOUSEHOLDS IF LESS THAN 10____
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

109) Does your household have:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A mobile telephone?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
An almirah or wardrobe?
YES 1
NO 2
A table?
YES 1
NO 2
A chair?
YES 1
NO 2
A watch?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter or tempo?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2
A rickshaw/van?
YES 1
NO 2

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
OTHER (SPECIFY)____ 96

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

KEROSENE 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

113) 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

115) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY)____ 96

116) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
BAMBOO 23
WOOD PLANKS 24
CARDBOARD 25
FINISHED ROOFING
TIN 31
WOOD 32
CERAMIC TILES 33
CEMENT 34
ROOFING SHINGLES 35
OTHER (SPECIFY)____ 96

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

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 22
STONE WITH MUD 23
PLYWOOD 24
CARDBOARD 25
FINISHED WALLS
TIN 31
CEMENT 32
STONE WITH LIME/CEMENT 33
BRICKS 34
WOOD PLANKS/SHINGLES 35
OTHER (SPECIFY)____ 96

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

ROOMS____

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

YES 1
NO 2 (GO TO 121)

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?

NUMBER OF COWS/BULLS/BUFFALOS____
NUMBER OF GOATS/SHEEP____
NUMBER OF CHICKENS/DUCKS____

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

YES 1
NO 2

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

YES 1
NO 2 (GO TO 501)

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

AMOUNT____\
SPECIFY UNIT____
ACRES____
DECIMALS_____

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

LINE NUMBER____
NAME____

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?

DAY____
MONTH____
YEAR____

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

YES 1
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 509)

505) WEIGHT IN KILOGRAMS

KILOGRAMS____

506) HEIGHT IN CENTIMETERS

CENTIMETERS____

507) MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

508) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

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)

LINE NUMBER____
NAME____

511) WEIGHT IN KILOGRAMS

KILOGRAMS____

512) HEIGHT IN CENTIMETERS

CENTIMETERS____

513) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

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.

Line number from household schedule of woman selected for domestic violence module____
Line number from household schedule of man selected for domestic violence module____