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NATIONAL FAMILIY HEALTH SURVEY, INDIA 2015-2016 (NFHS-4)
HOUSEHOLD QUESTIONNAIRE [STATE NAME]

IDENTIFICATION:

STATE____

DISTRICT____

TEHSIL/TALUK____

CITY/TOWN/VILLAGE____

TYPE OF PSU

URBAN 1
RURAL 2

PSU NUMBER___

STRUCTURE NUMBER___

HOUSEHOLD NUMBER___

NAME OF HOUSEHOLD HEAD____

ADDRESS OF HOUSEHOLD____

IS HOUSEHOLD SELECTED FOR THE STATE MODULE?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT
DATE___
INTERVIEWER'S NAME____
RESULT CODE___

NEXT VISIT
DATE____
TIME____

SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT CODE___

NEXT VISIT
DATE___
TIME___

THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT CODE___

SUPERVISOR'S NAME_____

FINAL VISIT
DAY___
MONTH__
YEAR__
INT. NO.___
RESULT__

TOTAL NUMBER OF VISITS___

SUPERVISOR NUMBER___

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

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 FOUND
9 = OTHER_____(SPECIFY)

LANGUAGE OF QUESTIONNAIRE_____
RESPONDENT'S MOTHER TONGUE___
LANGUAGE OF INTERVIEW___

TRANSLATOR USED?

YES 1
NO 2

LANGUAGE CODES:

01 = ASSAMESE
02 = BENGALI
03 = GUJARATI
04 = HINDI
05 = KANNADA
06 = KASHMIRI
07 = KONKANI
08 = MALAYALAM
09 = MANIPURI
10 = MARATHI
11 = NEPALI
12 = ORIYA
13 = PUNJABI
14 = SINDHI
15 = TAMIL
16 = TELUGU
17 = URDU
18 = ENGLISH
19 = GARO
20 = KHASI
96 = OTHER_____(SPECIFY)

INTRODUCTION AND INFORMED CONSENT
Namaste. My name is _______. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over India. The information on family welfare and health that we collect from households and individuals 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 25-35 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. Your participation in the survey is voluntary. 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.

If you have any questions about this survey you may ask me.
ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S CONCERNS.

If you have any further questions about this survey you may contact the persons listed on this card.
GIVE CARD WITH CONTACT INFORMATION.

Do you agree to participate in this survey?

SIGNATURE OF INTERVIWER___
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 NO.

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 NAME, RELATIONSHIP, SEX, RESIDENCE, AND AGE FOR EACH PERSON; ASK QUESTIONS 7A(a-c) TO BE SURE THAT THE LISTING IS COMPLETE.)

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/NEPHEW
11 = OTHER RELATIVE
12 = ADOPTED/FOSTER/STEPCHILD
13 = DOMESTIC SERVANT
14 = OTHER NOT RELATED
98 = DON'T KNOW

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

AGE
7) How old is (NAME)?
RECORD COMPLETED YEARS.

______(IN YEARS)
00 = AGE LESS THAN ONE YEAR
95 = AGE 95 YEARS OR MORE

7A) 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___

8) MARITAL STATUS
(IF AGE 13 OR OLDER)
What is the current marital status of (NAME)?____

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

ELIGIBILITY
9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54 (IF HOUSEHOLD IS SELECTED FOR STATE MODULE)

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

12) BIRTH REGISTRATION (IF AGE 0-4)
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
DON'T KNOW 8

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS (IF AGE 0-17)
13) Is (NAME)'s natural mother alive?

YES 1
NO 2 (SKIP TO 15)
DON'T KNOW 8 (SKIP TO 15)

14) Does (NAME)'s natural mother usually live in this household or was she a guest last night?

IF YES: What is her name?
IF YES: RECORD MOTHER'S LINE NUMBER
IF NO: RECORD '00'.
LINE NO.___

15) Is (NAME)'s natural father alive?

YES 1
NO 2 (SKIP TO 15)
DON'T KNOW 8 (SKIP TO 15)

16) Does (NAME)'s natural father usually live in this household or was he a guest last night?

IF YES: What is his name?
IF YES: RECORD FATHER'S LINE NUMBER
IF NO: RECORD '00'.
LINE NO.___

EDUCATION
(IF AGE 5 OR OLDER)
17) Has (NAME) attended school?

YES 1
NO 2 (SKIP TO 21A)

18) What is the highest standard (NAME) has completed?

STANDARD____
00 = LESS THAN 1 YEAR COMPLETED OR PRE-PRIMARY
98 = DON'T KNOW

IF AGE 15-18
19) Did (NAME) attend school or college at any time during the 2015-2016 school year?

YES 1
NO 2 (SKIP TO 21)

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

STANDARD___
00 = LESS THAN 1 YEARS COMPLETED OR PRE-PRIMARY
98 = DON'T KNOW

21) What is the main reason (NAME) is not attending school? (IF NO ON Q.19)

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

21A) AADHAAR CARD
Does (NAME) have an Aadhaar card?

YES 1
NO 2

22) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5

23) Does any usual resident of your household suffer from tuberculosis?

YES 1
NO 2 (SKIP TO 25)

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

LINE NO.___

24A) FOR EACH PERSON ASK: Has (NAME) received medical treatment for the tuberculosis?
IF YES, ASK: Where did (NAME) go?

YES, PUBLIC ONLY 1
YES, PRIVATE ONLY 2
YES, BOTH 3
NO 4

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

PIPED WATER
PIPED INTO DWELLING 11 (SKIP TO 29)
PIPED TO YARD/PLOT 12 (SKIP TO 29)
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 52 (SKIP TO 29)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
COMMUNITY RO PLANT 92
OTHER___(SPECIFCY) 96

26) Where is the water source located?

IN OWN DWELLING 1 (SKIP TO 29)
IN OWN YARD/PLOT 2 (SKIP TO 29)
ELSEWHERE 3

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

MINUTES____
DELIVERED TO DWELLING 000 (SKIP TO 29)
ON THE PREMISES 996 (SKIP TO 29)
DON'T KNOW 998

28) 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

29) Does this household do anything to the water to make it safer to drink?

YES 1
NO 2 (SKIP TO 31)
DON'T KNOW 8 (SKIP TO 31)

30) What does this household usually do to make the water safer to drink? Anything else? (RECORD ALL MENTIONED)

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

31) 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, DON'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 (SKIP TO 34)
OTHER___(SPECIFY) 96

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

YES 1
NO 2 (SKIP TO 34)

33) How many households use this toilet facility?

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

34) 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

35) What is the caste or tribe of the head of the household?

CASTE___(SPECIFY) 991
TRIBE_____(SPECIFY) 992
NO CASTE/TRIBE 993 (SKIP TO 37)
DON'T KNOW 998

36) Is this a scheduled caste, a schedules tribe, other backward class, or none of them?

SCHEDULED CASTE 1
SCHEDULED TRIBE 2
OTHER BACKWARD CLASS 3
NONE OF THEM 4
DON'T KNOW 8

37) Does your household have:

A. ELECTRICITY
YES 1
NO 2
B. MATTRESS
YES 1
NO 2
C. PRESSURE COOKER
YES 1
NO 2
D. CHAIR
YES 1
NO 2
E. COT/BED
YES 1
NO 2
F. TABLE
YES 1
NO 2
G. ELECTRIC FAN
YES 1
NO 2
H. RADIO/TRANSISTOR
YES 1
NO 2
I. B AND W TELEVISION
YES 1
NO 2
J. COLOUR TELEVISION
YES 1
NO 2
K. SEWING MACHINE
YES 1
NO 2
L. MOBILE TELEPHONE
YES 1
NO 2
M. LAND LINE TELEPHONE
YES 1
NO 2
N. INTERNET
YES 1
NO 2
O. COMPUTER
YES 1
NO 2
P. REFRIGERATOR
YES 1
NO 2
Q. AIR CONDITIONER/COOLER
YES 1
NO 2
R. WASHING MACHINE
YES 1
NO 2
S. WATCH/CLOCK
YES 1
NO 2
T. BICYCLE
YES 1
NO 2
U. MOTORCYCLE/SCOOTER
YES 1
NO 2
V. ANIMAL-DRAWN CART
YES 1
NO 2
W. CAR
YES 1
NO 2
X. WATER PUMP
YES 1
NO 2
Y. THRESHER
YES 1
NO 2
Z. TRACTOR
YES 1
NO 2

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

ELECTRICITY 01 (SKIP TO 40)
LPG/NATURAL GAS 02 (SKIP TO 40)
BIOGAS 03 (SKIP TO 40)
KEROSENE 04
COAL/LIGNITE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP WASTE 09
DUNG CAKES 10
NO FOOD COOKED IN HOUSEHOLD 95 (SKIP TO 42)
OTHER___(SPECIFY) 96

39) 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

40) Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (SKIP TO 42)
OUTDOORS 3 (SKIP TO 42)
OTHER___(SPECIFY) 6 (SKIP TO 42)

41) Do you have a separate room which is used as a kitchen?

YES 1
NO 2

42) 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

43) 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

44) 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

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

ROOMS____

46) Does any member of this household own this house or any other house?

YES 1
NO 2 (SKIP TO 48)

47) Who owns the house?

MALE MEMBER 1
FEMALE MEMBER 2
BOTH 3
DON'T KNOW 8

48) Does any member of this household own any agricultural land?

YES 1
NO 2 (SKIP TO 52)

49) Who owns this agricultural land?

MALE MEMBER 1
FEMALE MEMBER 2
BOTH 3
DON'T KNOW 8

50) How much agricultural land do members of this household own? (IF NOT IN ACRES, SPECIFY SIZE AND UNIT)_________

ACRES_____

51) Out of this land, how much is irrigated? (IF NOT IN ACRES, SPECIFY SIZE AND UNIT)______

ACRES____
NONE 9995
DON'T KNOW 9998

52) Does your household own any of the following animals:

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

53) Does any usual member of this household have a bank account or a post office account?

YES 1
NO 2
DON'T KNOW 8

54) Is any usual member of this household covered by a health scheme or health insurance?

YES 1
NO 2 (SKIP TO 56)
DON'T KNOW 8 (SKIP TO 56)

55) 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
STATE HEALTH INSURANCE SCHEME C
RASHTRIYA SWASTHYA BIMA YOJANA (RSBY) D
COMMUNITY HEALTH INSURANCE PROGRAMME E
OTHER HEALTH INSURANCE THROUGH EMPLOYER F
MEDICAL REIMBURSEMENT FROM EMPLOYER G
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE H
OTHER___(SPECIFY) X

56) When members of your household get sick, where do they generally go for treament?

PUBLIC HEALTH SECTOR
GOVT./MUNICIPAL HOSPITAL 11 (SKIP TO 58)
GOVT. DISPENSARY 12 (SKIP TO 58)
UHC/UHP/UFWC 13 (SKIP TO 58)
CHC/RURAL/HOSPITAL/BLOCK PHC 14 (SKIP TO 58)
PHS / ADDITIONAL PHC 15 (SKIP TO 58)
SUB-CENTRE 16 (SKIP TO 58)
VAIDYA/HAKIM/HOMEOPATH (AYUSH) 17 (SKIP TO 58)
ANGANWAD/ICDS CENTRE 18 (SKIP TO 58)
ASHA 19
GOVT. MOBILE CLINIC 20
OTHER PUBLIC SECTOR HEALTH FACILITY 21
NGO OR TRUST HOSPITAL/CLINIC 31
PRIVATE HEALTH SECTOR
PVT. HOSPITAL 41
PVT. DOCTOR/CLINIC 42
PVT. PARAMEDIC 43
VAIDYA/HAKIM/HOMEOPATH (AYUSH) 44
TRADITIONAL HEALER 45
PHARMACY/DRUGSTORE 46
DAI (TBA) 47
OTHER PRIVATE SECTOR HEALTH FACILITY 48
OTHER
SHOP 51
HOME TREAMENT 52
OTHER___(SPECIFY) 96

57) 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

58) Does this household have a BPL card?

YES 1
NO 2
DON'T KNOW 8

59) Does your household have any mosquito nets that can be used while sleepig?

YES 1
NO 2 (SKIP TO 66)

60) How many mosquito nets does your household have? (IF 7 OR MORE NETS, RECORD '7').

NUMBER OF NETS___

61) From where did you get the mosquito net(s)? RECORD ALL MENTIONED.

PURCHASED FROM THE MARKET A
GOVERNMENT B
SUPPLISED BY NGO/TRUST C
OTHER___(SPECIFY) X
DON'T KNOW Z

62) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
DAWA PLUS 11
DURANET 12
INTERCEPTOR 13
LIFENET 14
MAGNET 15
NETPROTECT 16
OLYSET 17
PERMANET 18
ROYAL SENTRY 19
YORKOOL 20
OTHER/DK BRAND 26
'PRETREATED' NET 30
OTHER BRAND 96
DK BRAND 98

63) Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (SKIP TO 65)
NOT SURE 8 (SKIP TO 65)

64) Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME___
LINE NO.___

65) GO BACK TO 62 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 66.

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

OBSERVED 1
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (SKIP TO 69)
NOT OBSERVED, NO PERMISSION TO SEE 3 (SKIP TO 69)
NOT OBSERVED, OTHER REASON 4 (SKIP TO 69)

67) OBSERVATION ONLY: OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

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

69) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED___ (SPECIFY REASON) 6

70) Did any usual member of this household die since January 2013?

YES 1
NO 2 (END)

71) How many persons died?

TOTAL DEATHS___

72) Please tell the name(s) of the (person/people) who died.

NAME___

73) Was (NAME) male or female?

MALE 1
FEMALE 2

74) How old was (NAME) when (he/she) died?

DAYS___
MONTHS___
YEARS___

75) In what month and year did (NAME) die?

MONTH__
YEAR____

76) Was the death due to an accident, violence, poisoning, homicide, or suicide?

YES 1 (GO TO NEXT LINE)
NO 2

77) IF FEMALE AND DIED WHEN 12 YEARS OR OLDER: Did (NAME) die during pregnancy, during childbirth, or within two months after the end of pregnancy or childbirth?

YES 1
NO 2

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT RESPONDENT: _____
COMMENTS ON SPECIFIC QUESTIONS: ____
ANY OTHER COMMENTS: _____
SUPERVISOR'S OBSERVATIONS: _____
NAME OF SUPERVISOR: _________
DATE: ____