HOUSEHOLD QUESTIONNAIRE [STATE NAME]
IDENTIFICATION:
STATE____
DISTRICT____
TEHSIL/TALUK____
CITY/TOWN/VILLAGE____
RURAL 2
STRUCTURE NUMBER___
HOUSEHOLD NUMBER___
NAME OF HOUSEHOLD HEAD____
ADDRESS OF HOUSEHOLD____
IS HOUSEHOLD SELECTED FOR THE STATE MODULE?
NO 2
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 PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___
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
LANGUAGE OF QUESTIONNAIRE_____
RESPONDENT'S MOTHER TONGUE___
LANGUAGE OF INTERVIEW___
NO 2
BENGALI 02
GUJARATI 03
HINDI 04
KANNADA 05
KASHMIRI 06
KONKANI 07
MALAYALAM 08
MANIPURI 09
MARATHI 10
NEPALI 11
ORIYA 12
PUNJABI 13
SINDHI 14
TAMIL 15
TELUGU 16
URDU 17
ENGLISH 18
GARO 19
KHASI 20
OTHER_____(SPECIFY) 96
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 DOES NOT AGREE TO BE INTERVIEWED 2 (END)
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.
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.)
3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
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?
FEMALE 2
RESIDENCE
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
AGE
7) How old is (NAME)?
RECORD COMPLETED 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?
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?
NO___
c) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO___
8) MARITAL STATUS
(IF AGE 13 OR OLDER)
What is the current marital status of (NAME)?____
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?
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?
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: RECORD MOTHER'S LINE NUMBER
IF NO: RECORD '00'.
LINE NO.___
15) Is (NAME)'s natural father alive?
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: RECORD FATHER'S LINE NUMBER
IF NO: RECORD '00'.
LINE NO.___
EDUCATION
(IF AGE 5 OR OLDER)
17) Has (NAME) attended school?
NO 2 (SKIP TO 21A)
18) What is the highest standard (NAME) has completed?
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?
NO 2 (SKIP TO 21)
20) During (this/that) school year, what standard/year (is/was) (NAME) attending?
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)
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?
NO 2
22) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5
23) Does any usual resident of your household suffer from tuberculosis?
NO 2 (SKIP TO 25)
24) Who suffers from tuberculosis? Anyone else? RECORD LINE NUMBER(S). IF NO MORE TB CASES, RECORD '95'.
24A) FOR EACH PERSON ASK: Has (NAME) received medical treatment for the tuberculosis?
IF YES, ASK: Where did (NAME) go?
YES, PRIVATE ONLY 2
YES, BOTH 3
NO 4
25) What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 29)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
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
COMMUNITY RO PLANT 92
OTHER___(SPECIFCY) 96
26) Where is the water source located?
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?
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 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?
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)
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 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
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?
NO 2 (SKIP TO 34)
33) How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
34) What is the religion of the head of the household?
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?
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 TRIBE 2
OTHER BACKWARD CLASS 3
NONE OF THEM 4
DON'T KNOW 8
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
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
38) What type of fuel does your household mainly use for cooking?
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?
CHULLAH 2
OPEN FIRE 3
OTHER___(SPECIFY) 6
40) Is the cooking usually done in the house, in a separate building, or outdoors?
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?
NO 2
42) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
SAND 12
DUNG 13
PALM/BAMBOO 22
BRICK 23
STONE 24
VINYL OR ASPHALT 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
POLISHED STONE/MARBLE/GRANITE 36
43) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION
THATCH/PALM LEAF/REED/GRASS 12
MUD 13
SOD/MUD AND GRASS MIXTURE 14
PLASTIC/POLYTHENE SHEETING 15
PALM/BAMBOO 22
RAW WOOD PLANKS/TIMBER 23
UNBURNT BRICK 24
LOOSELY PACKED STONE 25
WOOD 32
CALAMINE/CEMENT FIBER 33
ASBESTOS SHEETS 34
RCC/RBC/CEMENT/CONCRETE 35
ROOFING SHINGLES 36
TILES 37
SLATE 38
BURNT BRICK 39
44) MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.
CANE/PALM/TRUNKS/BAMBOO 12
MUD 13
GRASS/REEDS/THATCH 14
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
UNBURNT BRICK 25
RAW WOOD/REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BURNT BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
GI/METAL/ASBESTOS SHEETS 36
45) How many rooms in this household are used for sleeping?
46) Does any member of this household own this house or any other house?
NO 2 (SKIP TO 48)
FEMALE MEMBER 2
BOTH 3
DON'T KNOW 8
48) Does any member of this household own any agricultural land?
NO 2 (SKIP TO 52)
49) Who owns this agricultural land?
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)_________
51) Out of this land, how much is irrigated? (IF NOT IN ACRES, SPECIFY SIZE AND UNIT)______
NONE 9995
DON'T KNOW 9998
52) Does your household own any of the following animals:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
53) Does any usual member of this household have a bank account or a post office account?
NO 2
DON'T KNOW 8
54) Is any usual member of this household covered by a health scheme or health insurance?
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)
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?
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
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
HOME TREAMENT 52
57) Why don't members of your household generally go to a government facility when they are sick? Any other reason? (RECORD ALL MENTIONED)
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?
NO 2
DON'T KNOW 8
59) Does your household have any mosquito nets that can be used while sleepig?
NO 2 (SKIP TO 66)
60) How many mosquito nets does your household have? (IF 7 OR MORE NETS, RECORD '7').
61) From where did you get the mosquito net(s)? RECORD ALL MENTIONED.
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.
DURANET 12
INTERCEPTOR 13
LIFENET 14
MAGNET 15
NETPROTECT 16
OLYSET 17
PERMANET 18
ROYAL SENTRY 19
YORKOOL 20
OTHER/DK BRAND 26
OTHER BRAND 96
DK BRAND 98
63) Did anyone sleep under this mosquito net last night?
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.
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.
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 NOT AVAILABLE 2
68) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.
ASH, MUD, SAND B
NONE C
69) ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT. TEST SALT FOR IODINE.
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?
NO 2 (END)
72) Please tell the name(s) of the (person/people) who died.
73) Was (NAME) male or female?
FEMALE 2
74) How old was (NAME) when (he/she) died?
MONTHS___
YEARS___
75) In what month and year did (NAME) die?
YEAR____
76) Was the death due to an accident, violence, poisoning, homicide, or suicide?
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?
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: ____