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NATIONAL FAMILY HEALTH SURVEY, INDIA 2005-2006 (NFHS- 3) HOUSEHOLD QUESTIONNAIRE [STATE NAME]

IDENTIFICATION

STATE _________
DISTRICT ________
TEHSIL/TALUK _________
CITY/TOWN/VILLAGE ________

MEGA CITY/LARGE CITY/SMALL CITY/LARGE TOWN/SMALL TOWN/RURAL _____

MEGA CITY 1
LARGE CITY 2
SMALL CITY 3
LARGE TOWN 4
SMALL TOWN 5
RURAL 6

PSU NUMBER _____________
HOUSEHOLD HUMBER ____________
NAME OF HOUSEHOLD HEAD _________
ADDRESS OF HOUSEHOLD __________

HOUSEHOLD IS SELECTED FOR MAN'S INTERVIEW?

YES 1
NO 2

HOUSEHOLD IS SELECTED FOR HIV TESTING?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE ______
INTERVIEWR'S NAME _______
RESULT ______

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 FOUND
9 OTHER (SPECIFY) _________

NEXT VISIT
DATE ______
TIME ______

FINAL VISIT
DAY _____
MONTH ______
YEAR _____
INT.NUMBER ______
RESULT CODE ______

TOTAL NUMBER OF VISITS ______

TOTAL PERSONS IN HOUSEHOLD ______
TOTAL ELIGIBLE WOMEN ______
TOTAL ELIGIBLE MEN ______

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

SUPERVISOR
NAME ________
DATE ________

FIELD EDITOR
NAME ________
DATE ________

OFFICE EDITOR ______
KEYED BY ______

Namaste. My name is _______ and I am working with (NAME OF ORGANIZATION). We are conducting a national survey about the health of women, men, and children, including information on household membership, living conditions, and use of health facilities. We would very much appreciate the participation of your household in this survey. I would like to ask you some questions about your household. The survey usually takes about 25 minutes to complete.
Whatever information you provide will be kept strictly confidential.

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

At this time, do you want to ask me anything about the survey?
ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S CONCERNS.

In case you need more information about the survey, you may contact these persons.
GIVE CARD WITH CONTACT INFORMATION.

May I begin the interview now?

SIGNATURE OF INTERVIEWER _______
DATE _______

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

HOUSEHOLD SCHEDULE

Now we would like some information about the people who usually live in your household or who are staying with you now.

1. LINE NUMBER

LINE NO. ______

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.

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 BROTHER-IN-LAW OR SISTER-IN-LAW
10 NIECE OR NEPHEW
11 OTHER RELATIVE
12 ADOPTED/FOSTER/STEP-CHILD
13 DOMESTIC SERVANT
14 OTHER NOT RELATED
98 DOESN'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)?

IN YEARS _______
00 AGE LESS THAN ONE YEAR
95 AGE 95 YEARS OR MORE

MARITAL STATUS. IF AGE 10 OR OLDER:

8. What is the current marital status of (NAME)?

CURRENTLY MARRIED 1
MARRIED, BUT GAUNA NOT PERFORMED 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
DESERTED 6
NEVER MARRIED 7
DOESN'T KNOW 8

ELIGIBILITY:
9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

ELIGIBILITY:
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-54

ELIGIBILITY:
11. CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6

BIRTH REGISTRATION. IF AGE 0-4:

12. Does (NAME) have a birth certificate?
IF NO: Has (NAME)'s birth ever been registered with the civil authority?

CERTIFICATE 1
REGISTRATION 2
NEITHER 3
DOESN'T KNOW 8

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS. IF AGE 0-17 YEARS:

13. Does (NAME)'s natural mother live in this household or did she stay here last night?
IF YES: What is her name? RECORD MOTHER'S LINE NUMBER.
IF NO: Is she alive? IF DEAD, RECORD '95'.
IF ALIVE BUT NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

LINE NO. _______

14. Does (NAME)'s natural father live in this household or did he stay here last night?
IF YES: What is his name? RECORD FATHER'S LINE NUMBER.
IF NO: Is he alive? IF DEAD, RECORD '95'.
IF ALIVE BUT NOT LISTED IN THE HOUSEHOLD, RECORD '00'.

LINE NO. _______

EDUCATION. IF AGE 5 YEARS OR OLDER:

15. Can (NAME) read and write?

YES 1
NO 2

16. Has (NAME) ever attend school?

YES 1
NO 2 (GO TO 23)

17. What is the highest standard (NAME) has completed?

STANDARD _______
00 LESS THAN ONE YEAR COMPLETED
98 DOESN'T KNOW

EDUCATION. IF AGE 5-18 YEARS:

18. Did (NAME) attend school or college at any time during the 2005-2006 school year?

YES 1
NO 2 (GO TO 20)

19. During this/that school year, what standard/ year is/was (NAME) attending?

STANDARD ______
98 DOESN'T KNOW

20. Did (NAME) attend school or college at any time during the previous school year, that is, 2004 - 2005?

YES 1
NO 2 (GO TO 22)

21. During that school year, what standard/ year did (NAME) attend? (E)

STANDARD ______
DOESN'T KNOW 98

22. IF NO ON QUESTION 18: What is the main reason (NAME) is not attending school?

SCHOOL TOO FAR AWAY 01
TRANSPORT NOT AVAILABLE 02
FURTHER EDUCATION NOT CONSIDERED NECESSARY 03
REQUIRED FOR HOUSEHOLD WORK 04
REQUIRED FOR WORK ON FARM/FAMILY BUSINESS 05
REQUIRED FOR OUTSIDE WORK FOR PAYMENT IN CASH OR KIND 06
COSTS TOO MUCH 07
NO PROPER SCHOOL FACILITIES FOR GIRLS 08
NOT SAFE TO SEND GIRLS 09
NO FEMALE TEACHER 10
REQUIRED FOR CARE OF SIBLINGS 11
NOT INTERESTED IN STUDIES 12
REPEATED FAILURES 13
GOT MARRIED 14
DID NOT GET ADMISSION 15
OTHER 96
DOESN'T KNOW 98

CHILD LABOUR. IF AGE 5-14 YEARS:

23. During the past week, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: For pay?

1 YES, FOR PAY (CASH OR KIND)
2 YES, UNPAID
3 NO 9 (GO TO 25)

24. Since last (DAY OF THE WEEK), about how many hours did he/she do this work for someone who is not a member of this household?
IF MORE THAN ONE JOB, INCLUDE ALL JOBS.

HOURS _____ (GO TO 26)
LESS THAN ONE HOUR 00
95 HOURS OR MORE 95

25. At any time during the past year, did (NAME) do any kind of work for someone who is not a member of this household?
IF YES: For pay?

1 YES, FOR PAY (CASH OR KIND)
2 YES, UNPAID
3 NO

26. During the past week, did (NAME) help with household chores such as shopping, collecting firewood, cleaning, fetching water, or caring for children?

YES 1
NO 2 (GO TO 28)

27. Since last (DAY OF THE WEEK), about how many hours did he/she spend doing these chores?

HOURS _____
LESS THAN ONE HOUR 00
95 HOURS OR MORE 95

28. During the past week, did (NAME) do any other family work, such as work on the farm, or in a business or selling goods in the street?

YES 1
NO 2 (GO TO THE NEXT LINE)

29. Since last (DAY OF THE WEEK), about how many hours did he/she do this work?

HOURS ______
LESS THAN ONE HOUR 00
95 HOURS OR MORE 95

TICK HERE IF CONTINUATION QUESTIONNAIRE USED ______

4A. Just to make sure that I have a complete household listing:

a) Are there any other persons such as small children or infants that we have not listed?

YES ____ (ENTER EACH IN TABLE)
NO ____

b) 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 ____ (ENTER EACH IN TABLE)
NO ____

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

YES ____ (ENTER EACH IN TABLE)
NO ____

30. Does any usual resident of your household suffer from tuberculosis?

YES 1
NO 2 (GO TO 32)

31. Who suffers from tuberculosis? Anyone else?
RECORD LINE NUMBER(S). IF NO MORE TB CASES, RECORD '95'.

LINE NO. _______

31A. FOR EACH PERSON, ASK: Has (NAME) received medical treatment for the tuberculosis?

YES 1
NO 2

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 37)
PIPED TO YARD/PLOT 12 (GO TO 37)
PUBLIC TAP/STANDPIPE 13 (GO TO 34)
TUBE WELL OR BOREHOLE 21 (GO TO 34)
DUG WELL
PROTECTED WELL 31 (GO TO 34)
UNPROTECTED WELL 32 (GO TO 34)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 34)
UNPROTECTED SPRING 42 (GO TO 34)
RAINWATER 51 (GO TO 37)
TANKER TRUCK 61 (GO TO 34)
CART WITH SMALL TANK 71 (GO TO 34)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 34)
BOTTLED WATER 91
OTHER (SPECIFY) ________ 96 (GO TO 34)

33. 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 (GO TO 37)
PIPED TO YARD/PLOT 12 (GO TO 37)
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 37)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER (SPECIFY) ______ 96

34. Where is the water source located?

IN OWN DWELLING 1 (GO TO 37)
IN OWN YARD/PLOT 2 (GO TO 37)
ELSEWHERE 3

35. How long does it take to go there, get water, and come back in one trip?

MINUTES ______
ON THE PREMISES 996 (GO TO 37)
DOESN'T KNOW 998

36. Who usually goes to this source to fetch the water for your household?

ADULT WOMAN 1
ADULT MAN 2
FEMALE CHILD UNDER AGE 15 YEARS 3
MALE CHILD UNDER AGE 15 YEARS 4
OTHER (SPECIFY) _______ 6

37. Do you treat your water in any way to make it safer to drink?

YES 1
NO 2 (GO TO 39)
DOESN'T KNOW 8 (GO TO 39)

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

BOIL A
USE ALUM B
ADD BLEACH/CHLORINE TABLETS C
STRAIN THROUGH A CLOTH D
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) E
USE ELECTRONIC PURIFIER F
LET IT STAND AND SETTLE G
OTHER (SPECIFY) ______ X
DOESN'T KNOW Z

39. What kind of toilet 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, DOESN'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT (VIP)/BIOGAS LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
TWIN PIT/COMPOSTING TOILET 31
DRY TOILET 41
NO FACILITY/USES OPEN SPACE OR FIELD 51 (GO TO 42)
OTHER (SPECIFY) _______ 96

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

YES 1
NO 2 (GO TO 42)

41. How many households use this toilet facility?

NO. OF HOUSEHOLDS IF LESS THAN TEN 0____
TEN OR MORE HOUSEHOLDS 95
DOESN'T KNOW 98

42. When members of your household get sick, where do they generally go for treatment?

PUBLIC MEDICAL SECTOR
GOVT./MUNICIPAL HOSPITAL 11 (GO TO 44)
GOVT. DISPENSARY 12 (GO TO 44)
UHC/UHP/UFWC 13 (GO TO 44)
CHC/RURAL HOSPITAL/PHC 14 (GO TO 44)
SUB-CENTRE 15 (GO TO 44)
ANGANWADI/ICDS CENTRE 16 (GO TO 44)
GOVT. MOBILE CLINIC 17 (GO TO 44)
OTHER PUBLIC SECTOR HEALTH FACILITY 18 (GO TO 44)
NGO OR TRUST HOSPITAL/CLINIC 21
PRIVATE MEDICAL SECTOR
PVT. HOSPITAL 31
PVT. DOCTOR/CLINIC 32
PVT. PARAMEDIC 33
VAIDYA/HAKIM/HOMEOPATH 34
TRADITIONAL HEALER 35
PHARMACY/DRUGSTORE 36
DAI (TBA) 37
OTHER PRIVATE SECTOR HEALTH FACILITY 38
OTHER
SHOP 41
HOME TREATMENT 42
OTHER (SPECIFY) ______ 96

43. Why don't members of your household generally go to a government facility when they are sick? Any other reason?
RECORD ALL MENTIONED.

NO NEARBY FACILITY A
FACILITY TIMING NOT CONVENIENT B
HEALTH PERSONNEL OFTEN ABSENT C
WAITING TIME TOO LONG D
POOR QUALITY OF CARE E
OTHER (SPECIFY) _______ X

44. What is the religion of the head of the household?

HINDU 01
MUSLIM 02
CHRISTIAN 03
SIKH 04
BUDDHIST/NEO-BUDDHIST 05
JAIN 06
JEWISH 07
PARSI/ZOROASTRIAN 08
NO RELIGION 09
OTHER (SPECIFY) ________ 96

45. What is the caste or tribe of the head of the household?

CASTE (SPECIFY) _______ 1
TRIBE (SPECIFY) _______ 2
NO CASTE/TRIBE 3 (GO TO 47)
DOESN'T KNOW 8

46. Is this a scheduled caste, a scheduled tribe, other backward class, or none of them?

SCHEDULED CASTE 1
SCHEDULED TRIBE 2
OBC 3
NONE OF THEM 4

47. Does your household have:

ELECTRICITY
YES 1
NO 2
MATTRESS
YES 1
NO 2
PRESSURE COOKER
YES 1
NO 2
CHAIR
YES 1
NO 2
COT/BED
YES 1
NO 2
TABLE
YES 1
NO 2
ELECTRIC FAN
YES 1
NO 2
RADIO/TRANSISTOR
YES 1
NO 2
B AND W TELEVISION
YES 1
NO 2
COLOUR TELEVISION
YES 1
NO 2
SEWING MACHINE
YES 1
NO 2
MOBILE TELEPHONE
YES 1
NO 2
ANY OTHER TELEPHONE
YES 1
NO 2
COMPUTER
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
WATCH/CLOCK
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE/SCOOTER
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR
YES 1
NO 2
WATER PUMP
YES 1
NO 2
THRESHER
YES 1
NO 2
TRACTOR
YES 1
NO 2

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

ELECTRICITY 01 (GO TO 51)
LPG/NATURAL GAS 02 (GO TO 51)
BIOGAS 03 (GO TO 51)
KEROSENE 04
COAL/LIGNITE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP WASTE 09
DUNG CAKES 10
OTHER (SPECIFY) ________ 96

49. In this household, is food cooked on a stove, a chullah or an open fire?

STOVE 1
CHULLAH 2
OPEN FIRE 3
OTHER (SPECIFY) ________ 6

50. Is the cooking done under a chimney?

YES 1
NO 2

51. 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 53)
OUTDOORS 3 (GO TO 53)
OTHER (SPECIFY) ______ 6 (GO TO 53)

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

YES 1
NO 2

53. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
MUD/CLAY/EARTH 11
SAND 12
DUNG 13
RUDIMENTARY FLOOR
RAW WOOD PLANKS 21
PALM/BAMBOO 22
BRICK 23
STONE 24
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
POLISHED STONE/MARBLE/ GRANITE 36
OTHER (SPECIFY) ______ 96

54. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF/REED/GRASS 12
MUD 13
SOD/MUD AND GRASS MIXTURE 14
PLASTIC/POLYTHENE SHEETING 15
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
RAW WOOD PLANKS/TIMBER 23
UNBURNT BRICK 24
LOOSELY PACKED STONE 25
FINISHED ROOFING
METAL/GI 31
WOOD 32
CALAMINE/CEMENT FIBER 33
ASBESTOS SHEETS 34
RCC/RBC/CEMENT/CONCRETE 35
ROOFING SHINGLES 36
TILES 37
SLATE 38
BURNT BRICK 39
OTHER (SPECIFY) _______ 96

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

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS/BAMBOO 12
MUD 13
GRASS/REEDS/THATCH 14
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
UNBURNT BRICK 25
RAW WOOD/REUSED WOOD 26
FINISHED WALLS
CEMENT/CONCRETE 31
STONE WITH LIME/CEMENT 32
BURNT BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
GI/METAL/ASBESTOS SHEETS 36
OTHER (SPECIFY) ______ 96

56. TYPE OF WINDOWS.
RECORD OBSERVATION.

ANY WINDOWS
YES 1
NO 2
WINDOWS WITH GLASS
YES 1
NO 2
WINDOWS WITH SCREENS
YES 1
NO 2
WINDOWS WITH CURTAINS OR SHUTTERS
YES 1
NO 2

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

ROOMS_____

58. Does this household own this house or any other house?

YES 1
NO 2

QUESTIONS ON SECURITY OF TENURE ASKED ONLY IN MUMBAI AND KOLKATA:

58. Does this household own this house or any other house?

THIS HOUSE ONLY 1
OTHER HOUSE(S) ONLY 2 (GO TO 58B)
BOTH THIS AND OTHER HOUSE(S) 3
NEITHER 4 (GO TO 58B)

58A. Do you or someone else in this household have a document for the ownership of this dwelling?

YES 1 (GO TO 58D)
NO 2 (GO TO 58D)
DOESN'T KNOW 8 (GO TO 58D)

58B. Do you or someone else in this household pay rent for this dwelling, live here as part of your employment terms, or have some other arrangement?

RENT 1
PART OF EMPLOYMENT AGREEMENT 2 (GO TO 58D)
OTHER ARRANGEMENT 3 (GO TO 58D)

58C. Do you have a written rental contract for this dwelling?

YES 1
NO 2
DOESN'T KNOW 8

58D. Do you feel secure from eviction from this dwelling?

YES 1
NO 2
DOESN'T KNOW 8

58E. DWELLING LOCATED IN OR NEAR:
RECORD OBSERVATION

a. LANDSLIDE AREA
YES 1
NO 2
b. FLOOD PRONE AREA
YES 1
NO 2
c. RIVER BANK
YES 1
NO 2
d. STEEP HILL
YES 1
NO 2
e. GARBAGE DUMPING GROUND
YES 1
NO 2
f. INDUSTRIAL POLLUTION AREA
YES 1
NO 2
g. RAILROAD
YES 1
NO 2
h. POWER PLANT
YES 1
NO 2
i. FLYOVER
YES 1
NO 2

59. Does this household own any agricultural land?

YES 1
NO 2 (GO TO 62)

60. How much agricultural land does this household own?
IF NOT IN ACRES, SPECIFY SIZE AND UNIT

SIZE AND UNIT ______
ACRES _______

61. Out of this land, how much is irrigated?
IF NOT IN ACRES, SPECIFY SIZE AND UNIT

SIZE AND UNIT ______
ACRES ______
NONE 9995

62. Does your household own any of the following animals:

Cows, bulls, or buffaloes?
Camels?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens or ducks?

COWS/BULLS/BUFFALOES
YES 1
NO 2
CAMELS
YES 1
NO 2
HORSES/DONKEYS/MULES
YES 1
NO 2
GOATS
YES 1
NO 2
SHEEP
YES 1
NO 2
CHICKENS/DUCKS
YES 1
NO 2

63. Does any usual member of this household have a bank account or a post office account?

YES 1
NO 2
DOESN'T KNOW 8

64. Is any usual member of this household covered by a health scheme or health insurance?

YES 1
NO 2 (GO TO 66)
DOESN'T KNOW 8 (GO TO 66)

65. What type of health scheme or health insurance?
Any other type?
RECORD ALL MENTIONED.

EMPLOYEES STATE INSURANCE SCHEME (ESIS) A
CENTRAL GOVERNMENT HEALTH SCHEME (CGHS) B
COMMUNITY HEALTH INSURANCE PROGRAMME C
OTHER HEALTH INSURANCE THROUGH EMPLOYER D
MEDICAL REIMBURSEMENT FROM EMPLOYER E
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE F
OTHER (SPECIFY) ________ X

66. Does this household have a BPL card?

YES 1
NO 2
DOESN'T KNOW 8

67. Does this household have any mosquito nets that can be used for sleeping?

YES 1
NO 2

68. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE. RECORD PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
LESS THAN 15 PPM 2
MORE THAN 15 PPM 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED (SPECIFY REASON) ______ 6

TABLE FOR SELECTION OF WOMEN FOR THE HOUSEHOLD RELATIONS QUESTIONS

INSTRUCTIONS:
LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE. FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE ELIGIBLE WOMAN WHO WILL BE ASKED THE HOUSEHOLD RELATIONS QUESTIONS. THEN, GO TO COLUMN (9) IN THE HOUSEHOLD SCHEDULE AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED ELIGIBLE WOMAN AND RECORD THIS HOUSEHOLD LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

FOR EXAMPLE, IF THE HOUSEHOLD QUESTIONNAIRE NUMBER IS '3716', GO TO ROW 6 AND CIRCLE THE ROW NUMBER ('6'). IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN 3 AND CIRCLE THE COLUMN NUMBER ('3'). DRAW LINES FROM ROW 6 AND COLUMN 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT ('2'). THIS MEANS YOU HAVE TO SELECT THE SECOND ELIGIBLE WOMAN. SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE WOMEN ARE '02', '03', AND '07'; THEN THE ELIGIBLE WOMAN FOR THE HOUSEHOLD RELATIONS QUESTIONS IS THE SECOND ELIGIBLE WOMAN, I.E., THE WOMAN WITH HOUSEHOLD LINE NUMBER '03'. PUT A * NEXT TO THIS WOMAN'S LINE NUMBER IN COLUMN (9) OF THE HOUSEHOLD SCHEDULE AND ALSO ENTER THE TWO DIGIT LINE NUMBER IN THE TWO BOXES AT THE BOTTOM OF THIS TABLE.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER _____

TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD _____

HOUSEHOLD LINE NUMBER OF WOMAN SELECTED FOR HOUSEHOLD RELATIONS SECTION ______

LINE NO. _____

WEIGHT, HEIGHT AND BIOMARKER MEASUREMENT

CHECK COLUMNS (9), (10), AND (11): RECORD THE LINE NUMBER, NAME, AND AGE OF ALL WOMEN AGE 15-49 AND CHILDREN UNDER AGE 6. IF THE HOUSEHOLD IS SELECTED FOR MEN'S INTERVIEWS, ALSO RECORD THE LINE NUMBER, NAME, AND AGE OF ALL MEN AGE 15-54.

WOMEN 15-49, MEN 15-54, CHILDREN UNDER AGE 6:

69. LINE NUMBER FROM QUESTION 9 OR 11

LINE NO._________

70. NAME FROM QUESTION 2

NAME________

71. AGE FROM QUESTION 7

YEARS _______

72A. NEVER MARRIED CHECK QUESTION 8. IS IT RESPONSE '7'?
[ASK FOR WOMEN 15-49 AND MEN 15-54 ONLY]

YES 1
NO 2

72B. CURRENTLY PREGNANT?
CHECK QUESTION 227 IN WOMAN'S QUESTIONNAIRE
[ASK FOR WOMEN 15-49 ONLY]

YES 1
NO/DOESN'T KNOW 2

72C. What is (NAME)'s date of birth?
[ASK FOR CHILDREN UNDER AGE 6 ONLY]

COPY MONTH AND YEAR FROM 215 IN THE MOTHER'S BIRTH HISTORY AND ASK DAY. FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH, AND YEAR.

DAY ____
MONTH ____
YEAR ____

WEIGHT AND HEIGHT MEASUREMENT OF WOMEN 15-49, MEN 15-54, CHILDREN UNDER AGE 6:

73. WEIGHT (KILOGRAMS)

KG ______

74. HEIGHT (CENTIMETERS)

CM ______

75. MEASURED LYING DOWN OR STANDING UP?
[ASK FOR CHILD UNDER AGE 6 ONLY]

LYING DOWN 1
STANDING UP 2

76. RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

TICK HERE IF CONTINUATION QUESTIONNAIRE USED _____

HAEMOGLOBIN AND HIV FOR WOMEN 15-49, MEN 15-54, AND CHILDREN BORN IN 2001 OR LATER:

77. CHECK QUESTIONS 71 AND 72A: IS RESPONDENT AGE 15-17 AND NEVER MARRIED?
FOR CHILDREN CHECK QUESTION 72C: CHILD BORN IN MONTH OF INTERVIEW OR PREVIOUS 5 MONTHS?

MEN AND WOMAN
YES 1
NO 2 (GO TO 79)
CHILDREN
YES 1 (NEXT CHILD)
NO 2

78. LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE.

LINE NO. _______

79. READ CONSENT STATEMENT FOR ANAEMIA TESTING TO (WO)MAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
FOR CHILDREN: READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)

MEN AND WOMEN
GRANTED 1 (SIGN) _______
REFUSED 2 (SIGN) ________
CHILDREN
GRANTED 1 (SIGN) ______
REFUSED 2 (SIGN) ______ (GO TO NEXT LINE)

80. READ CONSENT STATEMENT FOR HIV TESTING TO (WO)MAN/PARENT/RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
[ASK FOR WOMEN AND MEN ONLY]

GRANTED 1 (SIGN) ________
REFUSED 2 (SIGN) ________

81. HAEMOGLOBIN LEVEL (G/DL)

G/DL______

82. HAMEMOGLOBIN RESULT

1 MEASURED
2 NOT PRESENT
3 REFUSED
6 OTHER

83. HIV RESULT
[ASK FOR MEN AND WOMEN ONLY]

1 COLLECTED
2 NOT PRESENT
3 REFUSED
6 OTHER

84. PLACE BAR CODE BELOW
[ASK FOR MEN AND WOMEN ONLY]

PUT 1ST BAR CODE HERE _____
PUT 2ND BAR CODE ON RESPONDENT'S FILTER PAPER AND THIRD BAR CODE ON THE BLOOD TRANSMITTAL SHEET.

INFORMED CONSENT FOR ANAEMIA TESTING:

As part of this survey, we are studying anaemia among women, men, and children under age 6 years. Anaemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This information will assist the government to develop programmes to prevent and treat anaemia.

We request that (you/you and (NAME OF RESPONDENT'S CHILD (REN)/CHILD(REN) IN RESPONDENT'S CARE) born in 2001 or later participate in the anaemia testing part of this survey by giving a few drops of blood from a finger. The test uses disposable sterile instruments that are clean and completely safe. The blood will be tested with new equipment and the results of the test will be given to you immediately. The results will be kept confidential.

Do you have any questions?
ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S/GUARDIAN'S CONCERNS.

May I now ask that (you/you and NAME OF RESPONDENT'S CHILD(REN)/CHILD(REN) IN RESPONDENT'S CARE) participate in the anaemia testing. However, if you decide not to have the test(s) done, it is your right and we will respect your decision. Now please tell me if you agree to have the test(s) done.

GO TO COLUMN 79, CIRCLE THE APPROPRIATE CODE, AND SIGN.

IF RESPONDENT IS AGE 15-17 AND NEVER MARRIED, ASK PARENT/GUARDIAN:
Now, will you tell me if you accept that (NAME OF YOUTH(S)) participate in the anaemia testing?

GO TO COLUMN 78 AND WRITE THE LINE NUMBER OF THE PARENT/GUARDIAN. ASK FOR THEIR CONSENT. IF THE PARENT/GUARDIAN DOES NOT AGREE, CIRCLE CODE '2' IN COLUMN 79 AND SIGN. IF THE PARENT/GUARDIAN AGREES, READ THE PRECEDING PARAGRAPHS TO THE YOUTH FOR HIS/HER CONSENT, RECORD THE APPROPRIATE CODE IN COLUMN 79, AND SIGN. CIRCLE CODE '1' FOR 'GRANTED' ONLY IF BOTH THE PARENT/GUARDIAN AND THE YOUTH AGREE TO THE TESTING.

INFORMED CONSENT FOR HIV TEST FOR MEN AND WOMEN:

In addition to studying anaemia, we are also studying HIV. HIV is the virus that causes AIDS.

In order to determine how prevalent HIV is in India, we are asking women and men throughout India to give a few drops of blood. The drops of blood will be collected from your finger (at the same time as we do your anaemia test) and sent to a laboratory for testing. To ensure complete confidentiality of the collected blood, no individual names will be attached to the blood sample. This means that no one, including me, will be able to trace the blood sample or the test result back to you. Since we are only collecting blood on a filter paper with no other identifying information, we cannot give you the result of the HIV test.

However, whether or not you choose to participate in this effort to estimate the prevalence of HIV in India, you will be given a voucher for a free HIV test at a health clinic where you can get your blood tested for HIV if you want and receive your results.

Do you have any questions?
ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S CONCERNS.

I hope you will agree to give a few drops of blood from your finger for this very important country-wide effort, as it will help the government to develop programmes to prevent the spread of HIV and AIDS. However, if you decide not to participate, it is your right and we will respect your decision.

Do you agree to give a few drops of blood for anonymous HIV testing?

GO TO COLUMN 80 AND CIRCLE THE APPROPRIATE CODE AND SIGN.

IF RESPONDENT IS AGE 15-17 AND NEVER MARRIED, ASK THE PARENT/GUARDIAN: Now, will you tell me if you accept that (NAME OF YOUTH(S)) participate in the HIV testing?

IF THE PARENT/GUARDIAN DOES NOT AGREE, CIRCLE CODE '2' IN COLUMN 80 AND SIGN. IF THE PARENT/GUARDIAN AGREES, READ THE PRECEDING PARAGRAPHS TO THE YOUTH FOR HIS/HER CONSENT, RECORD THE APPROPRIATE CODE IN COLUMN 80, AND SIGN. CIRCLE CODE '1' FOR 'GRANTED' ONLY IF BOTH THE PARENT/GUARDIAN AND THE YOUTH AGREE TO THE TESTING.

85. CHECK 81:
NUMBER OF PERSONS WITH HAEMOGLOBIN LEVEL BELOW THE CUTOFF POINT OF 7 G/DL.

ONE OR MORE:
GIVE EACH WOMAN/MAN/PARENT/RESPONSIBLE ADULT ANAEMIA PAMPHLET WITH RESULT OF HAEMOGLOBIN MEASUREMENT AND CONTINUE WITH 86. [IF MORE THAN ONE WOMAN, MAN, OR CHILD IS BELOW THE CUTOFF POINT, READ THE STATEMENT IN QUESTION 86 TO EACH ADULT WHO IS BELOW THE CUTOFF POINT AND TO EACH PARENT/RESPONSIBLE ADULT OF A CHILD WHO IS BELOW THE CUTOFF POINT. FOR PERSONS AGE 15-17, CIRCLE CODE '1' ONLY IF BOTH THE PERSON AND THE PARENT/GUARDIAN AGREE THAT THE INFORMATION MAY BE PROVIDED TO THE DOCTOR.]
NONE:
GIVE EACH WOMAN/MAN/PARENT/RESPONSIBLE ADULT ANAEMIA PAMPHLET WITH RESULT OF HAEMOGLOBIN MEASUREMENT AND END INTERVIEW.

86. We detected a low level of haemoglobin in (your blood/the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have severe anaemia, which is a serious health problem. We would like to inform the doctor at ______ about (your condition/the condition of NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of haemoglobin in (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?

WOMEN AGE 18-49 AND MEN AGE 18-54:

NAME OF PERSON WITH HAEMOGLOBIN BELOW 7 G/DL

NAME ______

AGREES TO REFERRAL?

YES 1
NO 2

WOMEN AND MEN AGE 15-17 AND CHILDREN:

NAME OF PERSON WITH HAEMOGLOBIN BELOW 7 G/DL

NAME ______

NAME OF PARENT/RESPONSIBLE ADULT

NAME OF ADULT ______

AGREES TO REFERRAL?

YES 1
NO 2