NIPORT, MOHFW
Mitra and Associates
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 __________
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE _____
INTERVIEWER'S NAME ___________
RESULT* _____
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 _____
FINAL VISIT
DAY _____
MONTH _____
YEAR _____
INT. CODE _____
RESULT* _____
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 ____
FIELD EDITOR
NAME _____
OFFICE EDITOR ____
KEYED BY ____
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 DOES NOT AGREE TO BE INTERVIEWED 2 (END)
1. LINE NUMBER
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.
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
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?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
7. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD '95'. IF LESS THAN 1 YEAR THEN WRITE '0'.
8. MARITAL STATUS. IF AGE 15 OR OLDER: What is (NAME)'s current marital status?
DIVORCED/SEPARATED/DESERTED/WIDOWED 2
NEVER MARRIED 3
9. EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:
Has (NAME) ever attended school?
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?
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8
What is the highest class (NAME) completed at that level?
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?
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?
SECONDARY 2
HIGHER 3
PRE-PRIMARY 6
DON'T KNOW 8
98 DON'T KNOW
13. CURRENT WORK STATUS. IF AGE 8 OR OLDER: Is (NAME) currently working?
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?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
15. MOBILE PHONE. IF AGE 13 OR OLDER: Does (NAME) have a mobile phone?
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?
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?
NO ___
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO ___
102. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
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 YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
104A. Do you share this source with other household?
NO 2 (GO TO 105)
104B. How many households use this source of water?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
105. Do you do anything to the water to make it safer to drink?
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.
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 TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
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?
NO 2 (GO TO 110)
109. How many households use this toilet facility?
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?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
111. What type of fuel does your household mainly use for cooking?
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 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?
NO 2
114. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
PALM/BAMBOO 22
CERAMIC TILES 33
CEMENT 34
CARPET 35
115. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
116. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
DIRT 13
STONE WITH MUD 22
PLYWOOD 24
CARDBOARD 25
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?
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?
NO 2
NO 2
NO 2
NO 2
NO 2
121. Does this household own any livestock, herds, other farm animals, or poultry?
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?
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?
NO 2
122B. Does your household own any land (other than the homestead land)?
NO 2 (GO TO 123)
122C. How much land does your household own (other than the homestead land)?
SPECIFY UNIT _________
IF 95 OR MORE CIRCLE '9995'
95 OR MORE ACRES 9995
DON'T KNOW 9998
123. Does any member of this household have a bank account?
NO 2
137. Please show me where members of your household most often wash their hands.
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 NOT AVAILABLE 2
139. OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.
DETERGENT (BAR, LIQUID, POWDER) B
ASH, MUD, SAND C
NONE D
140. OBSERVATION ONLY:
OBSERVE TYPE OF PLACE FOR HAND WASHING
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.
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?
MONTH _____
YEAR _____
204. CHECK 203: CHILD BORN IN JANUARY 2009 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE CHILDREN, GO TO 214)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
207. MEASURED LYING DOWN OR STANDING UP?
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.
NAME ___________
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
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.