IDENTIFICATION

DIVISION_________
DISTRICT_________
UPAZILA_________
VILLAGE/MOHALLA/BLOCK________
CLUSTER NUMBER____
HOUSEHOLD NUMBER_____
RURAL 1
CITY CORPORATION 2
OTHER URBAN 3
NAME OF THE HOUSEHOLD HEAD_____

IS HOUSEHOLD SELECTED FOR BIOMARKER?

INTERVIEWER VISITS

DATE_____
INTERVIEWER'S NAME________
RESULT _________

NEXT VISIT_____
DATE_____
TIME_____
FINAL VISIT
DAY_____
MONTH_____
YEAR_____
INT. NO_____

TOTAL NUMBER OF VISITS_____
TOTAL PERSONS IN HOUSEHOLD_____
TOTAL EVER MARRIED WOMEN 15-49 YRS_____
TOTAL NUMBER OF CHILDREN 0-5 YRS
TOTAL WOMEN AND MEN 18+ YRS

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR
NAME_____________
NUMBER__________

FIELD EDITOR
NAME____________
NUMBER__________

OFFICE EDITOR
NUMBER___________

KEYED BY
NUMBER__________

Introductory Statement:

My name is ________________________. I am working for Mitra and Associates, a private research organization located in Dhaka. We are conducting a survey about health all over Bangladesh under the authority of the National Institute of Population Research and Training (NIPORT), Medical Education and Family Welfare Division, Ministry of Health and Family Welfare (MOHFW). The information we collect will help the government to plan health and family planning services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 30 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.

Why is the study being done?

The survey aims to provide information to address the monitoring and evaluation needs of the Fourth Health, Population and Nutrition Sector Program (HPNSP) and to provide managers and policy makers involved in this program with the information that they need to effectively plan and execute future interventions.
What is involved in the study?
You have been selected as a respondent in this survey. I would like to ask you some questions about your household and household members.

What will you have to do if you agree to participate?

Since you have been selected as a respondent in this study, I shall be thankful if you provide your valuable response on certain issues. If some questions cause you embarrassment or make you feel uncomfortable, you can refuse to answer them.
What are the risks and benefits of this study?
By providing information you will not have any risk whatsoever, rather this will help the government and policy planners to evaluate, strengthen and refocus national effort to improve health, population and nutrition programs.

Confidentiality:

Whatever information you provide will be kept strictly confidential. it will be used for research purposes and will be seen only by staff and researchers at the organizations mentioned.

Is there any compensation for participating in the study?

Your participation in the study is voluntary and promises no financial benefit.

Right to refuse or withdraw:

Participation in this survey is voluntary and you can choose not to answer any individual questions or all of the questions. However, we hope that you will participate in this survey since your views are important.

Who do I contact if I have a question or problem?

If you wish to know more about your rights as a participant in this study you may write the Bangladesh Medical Research Council (BMRC), Mohakhali, Dhaka or Mitra and Associates, Main Road 1, House 35, Senpara Parbata, Mirpur 10, Dhaka or Phone 9025410, 9025412. If you have further questions regarding the nature of this study you may also contact NIPORT, 13/1 Sheikh Shaheb Bazar, Azimpur, Dhaka-1205 or Phone 9662495, 58611206.

At this time, do you want to ask me anything about the survey?

SIGNATURE OF INTERVIEWER____________

DATE_______________

RECORD THE TIME.

HOURS_________
MINUTES_________
HOUSEHOLD SCHEDULE

1. LINE NUMBER

USUAL RESIDENTS AND VISITORS

2. Please give 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 PERONS, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

2A. Just to make sure that I have a complete listing: are there any other people 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 may have not been listed?

RELATIONSHIP TO HEAD OF HOUSEHOLD

3. What is the relationship of (NAME) to the head of the household?

SEX

4. 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 95 OR MORE, RECORD '95'.
IN YEARS______

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

EVER ATTENDED SCHOOL

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

10. What is the highest level of school (NAME) has attended?

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

CURRENT/RECENT SCHOOL ATTENDANCE

11. IF AGE 5-24 YEARS: Did (NAME) attend school at any time during the 2017 school year?

12. During [this/that] school year, what level and class [is/was] (NAME) attending?

CURRENT WORK STATUS

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

BIRTH REGISTRATION

14. 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?

14A. IF AGE 18 OR OLDER: NATIONAL ID CARD

MOBILE PHONE

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

BIOMARKER TESTING
ALL HOUSEHOLDS

WOMEN: INTERVIEW

15B. 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 1-3

WOMEN: WEIGHT/HEIGHT

16. 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 1-3

CHILDREN: WEIGHT/HEIGHT

17. CIRCLE LINE NUMBER OF ALL CHILD-REN AGE 0-5 YEARS IF COLUMN 7
IS 0-5

SELECTED HOUSEHOLDS

WOMEN: BP GLUCOSE

18. CIRCLE LINE NUMBER OF EVER-MARRIED WOMEN AGE 18-49 IF COLUMN 4 IS 2 AND IF COLUMN 7 IS 18-49, AND IF COLUMN 8 IS 1-3

WOMEN: WEIGHT/HEIGHT, BP GLUCOSE

19. CIRCLE LINE NUMBER OF EVER-MARRIED WOMEN AGE IS 50+ IF COLUMN 4 IS 2 AND IF COLUMN 7 IS 50+, AND IF COLUMN 8 IS 1-3, NEVER-MARRIED WOMEN AGE 18+ IF COLUMN 4 IS 2 AND IF COLUMN 7 IS 18+, AND IF COLUMN 8 IS 4.

MEN: WEIGHT/HEIGHT, BP GLUCOSE

20. CIRCLE LINE NUMBER OF ALL MEN AGE 18+ IF COLUMN 4 IS 1 AND IF COLUMN 7 IS 18+.

HOUSEHOLD CHARACTERISTICS

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

103. Where is that water source located?

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

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

109. What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

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

111. Including your own household, how many households use this toilet facility?

112. Where is this toilet facility located?

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

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

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

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

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

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

119. Does any member of this household own any homestead? IF 'NO' PROBE: Does your household own homestead in any other places?

119A. Does your household own any land other than the homestead land?

120. How much land do members of this household own other than the homestead land?

121. Does your household have:

122. Does any member of this household own:

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

ADDITIONAL HOUSEHOLD CHARACTERISTICS

125. WE WOULD LIKE TO LEARN ABOUT THE PLACES THAT HOUSEHOLDS USE TO WASH THEIR HANDS. CAN YOU PLEASE SHOW ME WHERE MEMBERS OF YOUR HOUSEHOLD MOST OFTEN WASH THEIR HANDS?

126. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.
RECORD OBSERVATION.

127. OBSERVE PRESENCE OF SOAP DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING.
RECORD OBSERVATION.

127A. OBSERVATION ONLY:
OBSERVE TYPE OF PLACE FOR HANDWASHING

128. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD THE OBSERVATION.

129. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.

130. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.

131. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:
___________________________________________________________
COMMENTS ON SPECIFIC QUESTIONS:
___________________________________________________________
ANY OTHER COMMENTS:
___________________________________________________________
SUPERVISOR'S OBSERVATIONS
___________________________________________________________
EDITOR'S OBSERVATION
___________________________________________________________