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June 11, 2014

BANGLADESH DEMOGRAPHIC AND HEALTH SURVEY 2014 HOUSEHOLD QUESTIONNAIRE

NIPORT, MOHFW
Mitra and Associates

IDENTIFICATION

DIVISION _____
DISTRICT _____
UPAZILA _____
UNION/WARD ____
VILLAGE/MOHALLA/BLOCK _____
CLUSTER NUMBER _____
HOUSHOLD NUMBER ____
RURAL=1, CITY CORPORATION=2, OTHER URBAN=3 _____
NAME OF THE HOUSEHOLD HEAD __________

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER'S NAME ___________
RESULT* _____

*RESULT CODES

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 FOUD
9 OTHER (SPECIFY) ______

NEXT VISIT
DATE ______
TIME _____

FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. CODE _____
RESULT* _____

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN (EVER MARRIED WOMEN 15-49 YR) _____
TOTAL NUMBER OF CHILDREN (0-5 YR) _____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____

SUPERVISOR
NAME _____

FIELD EDITOR
NAME _____

OFFICE EDITOR ____
KEYED BY ____

INTRODUCTION AND CONSENT

Hello. My name is __________. I am working with NIPORT, the Ministry of Health and Family Welfare, and Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all over Bangladesh. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you 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.
In case you need more information about the survey, you may contact with Mr. S. N Mitra, Executive Director, Mitra and Associates, 2/17 Iqbal Road, Block A, Hogammadpur, Dhaka 1207, Bangladesh. Telephone number are: 8118065, 9115503, 01711278663.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

NAME OF INTERVIEWER: __________
DATE: ______

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

HOUSEHOLD SCHEDULE

1. LINE NUMBER

LINE NO. _____

2. USUAL RESIDENTS AND VISITORS:
Please give me the names of the persons who usually live in your household who stayed here last night, starting with the head of the household.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSIHP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-22 FOR EACH PERSON.

NAME _____

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

01 HEAD
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED/FOSTER/STEPCHILD
11 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. RESIDENCE:
Did (NAME) stay here last night?

YES 1
NO 2

7. AGE:
How old is (NAME)?
IF 95 OR MORE, RECORD '95'. IF LESS THAN 1 YEAR THEN WRITE '0'.

AGE _____

8. MARITAL STATUS. IF AGE 15 OR OLDER:
What is (NAME)'s current marital status?

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

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

YES 1
NO 2 (GO TO 13)

10. EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:
What is the highest level of school (NAME) has attended?

LEVEL
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8

What is the highest class (NAME) completed at that level?

CLASS
CLASS ____
LESS THAN 1 YEAR COMPLETED 00
DON'T KNOW 98

11. CURRENT/RECENT SCHOOL ATTENDANCE. IF AGE 5-24 YEARS:
Did (NAME) attend school at any time during the 2014 school year?

YES 1
NO 2 (GO TO 13)

12. CURRENT/RECENT SCHOOL ATTENDANCE. IF AGE 5-24 YEARS:
During this/that school year (2014), what level and class [is/was] (NAME) attending?

LEVEL
PRIMARY 1
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8
CLASS
CLASS ____
98 DON'T KNOW

13. CURRENT WORK STATUS. IF AGE 8 OR OLDER:
Is (NAME) currently working?

YES 1
NO 2

14. BIRTH REGISTRATION. IF AGE 0-4 YEARS:
Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

HAS CERTIFICIATE 1
REGISTERED 2
NEITHER 3
DON'T KNOW 8

15. MOBILE PHONE. IF AGE 13 OR OLDER:
Does (NAME) have a mobile phone?

YES 1
NO 2

ELIGIBILITY:
16. INTERVIEW - WOMEN:

CIRCLE LINE NUMBER OF ALL EVER-MARRIED WOMEN AGE 15-49 IF COLUMN 4 IS 2 AND IF COLUMN 7 IS 15-49, AND IF COLUMN 8 IS 1 OR 2.

ELIGIBILITY:
17. ANTHROPOMETRY - CHILDREN:

CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 IF COLUMN 7 IS 0 TO 5.

ELIGIBILITY:
18. ANTHROPOMETRY - WOMEN:

CIRCLE LINE NUMBER OF ALL EVER-MARRIED WOMEN AGE 15-49 IF COLUMN 4 IS 2 AND IF COLUMN 7 IS 15-49 AND IF COLUMN 8 IS 1 OR 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 hat 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

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 105)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) _____ 96

103. Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

104. How long does it take to go there, get water, and come back?

MINUTES ____
DON'T KNOW 998

104A. Do you share this source with other household?

YES 1
NO 2 (GO TO 105)

104B. How many households use this source of water?

NO. OF HOUSEHOLDS IF LESS THAN 10 ____
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

105. Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 107)
DON'T KNOW 8 (GO TO 107)

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

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

107. What kind of toliet facility do members of your household usually 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
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 110)
OTHER (SPECIFY) _____ 96

108. Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 110)

109. How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN 10 ____
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

110. Does your household have:

Electricity?
Solar Electricity?
A radio?
A television?
A mobile telephone?
A non-mobile telephone?
A refrigerator?
An almirah/wardrobe?
An electric fan?
A DVD/VCD player?
A water pump?
An IPS/generator?
An air conditioner?
A computer/laptop?

ELECTRICITY
YES 1
NO 2
SOLAR ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
ALMIRAH/WARDROBE
YES 1
NO 2
ELECTRIC FAN
YES 1
NO 2
DVD/VCD PLAYER
YES 1
NO 2
WATER PUMP
YES 1
NO 2
IPS/GENERATOR
YES 1
NO 2
AIR CONDITIONER
YES 1
NO 2
COMPUTER/LAPTOP
YES 1
NO 2

111. 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
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) ____ 96

112. Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFIY) _____ 6 (GO TO 114)

113. Do you have a separate room which is used as a kitchen?

YES 1
NO 2

114. 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

115. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
TIN 31
WOOD 32
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY) ____ 96

116. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
PLYWOOD 24
CARDBOARD 25
FINISHED WALLS
TIN 31
CEMENT 32
STONE WITH LIME/CEMENT 33
BRICKS 34
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) _____ 96

117. How many rooms in this household are used for sleeping?

ROOMS _____

118. Does any member of this household own:

A car/truck/microbus?
An autobike/tempo/CNG?
A rickshaw/van?
A bicycle?
A motorcycle or motor scooter?

CAR/TRUCK/MICROBUS
YES 1
NO 2
AUTOBIKE/TEMPO/CNG
YES 1
NO 2
RICKSHAW/VAN
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2

121. Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
NO 2 (GO TO 122A)

122. How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.

Buffaloes?
Cows?
Goats or sheep?
Chickens or ducks?
Other farm animals?

BUFFALOES ____
MILK COWS/BULLS ____
GOAT/SHEEP ____
CHICKENS/DUCKS ____
OTHER FARM ANIMALS ____

122A. Does your household own any homestead?
IF 'NO' PROBE:
Does your household own homestead in any other places?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 123)

122C. How much land does your household own (other than the homestead land)?

AMOUNT _______
SPECIFY UNIT _________
IF 95 OR MORE CIRCLE '9995'
AREA (ACRES. DECIMALS) _____.____
95 OR MORE ACRES 9995
DON'T KNOW 9998

123. Does any member of this household have a bank account?

YES 1
NO 2

137. Please show me where members of your household most often wash their hands.

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 201)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 201)
NOT OBSERVED, OTHER REASON 4 (GO TO 201)

138. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLANCE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

139. OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

SOAP (BAR, LIQUID, PASTE) A
DETERGENT (BAR, LIQUID, POWDER) B
ASH, MUD, SAND C
NONE D

140. OBSERVATION ONLY:
OBSERVE TYPE OF PLACE FOR HAND WASHING

COVERED SPACE (INSIDE DWELLING) 1
OPEN SPACE, NOT SHARED 2
OPEN SPACE, SHARED 3

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5

CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
MEASURER CODE _____

201. CHECK COLUMN 17 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202. LINE NUMBER FROM COLUMN 17.
NAME FROM COLUMN 2.

LINE NUMBER _____
NAME ___________

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

DAY _____
MONTH _____
YEAR _____

204. CHECK 203: CHILD BORN IN JANUARY 2009 OR LATER?

YES 1
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)

205. WEIGHT IN KILOGRAMS

KG. ____._____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

206. HEIGHT IN CENTIMETERS

CM. _____.___

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

207. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2
NOT MEASURED 3

213. GO BACK TO 203 IN THE NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214

WEIGHT AND HEIGHT MEASUREMENT FOR EVER-MARRIED WOMEN AGE 15-49

CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____
MEASURER CODE _____

214. CHECK COLUMN 18 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME OF ALL ELIGIBLE EVER-MARRIED WOMEN IN 215. IF THERE ARE MORE THAN THREE EVER MARRIED WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215. LINE NUMBER FROM COLUMN 18.
NAME FROM COLUMN 2.

LINE NUMBER _____
NAME ___________

216. WEIGHT IN KILOGRAMS

KG. _____._____

NOT PRESENT 99994
REFUSED 99995
OTHER 99996

217. HEIGHT IN CENTIMETERS

CM. _____.____

NOT PRESENT 9994
REFUSED 9995
OTHER 9996

223. GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE EVER-MARRIED WOMEN AGE 15-49, END MEASUREMENT.