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JORDAN POPULATION AND FAMILY HEALTH SURVEY 1996 HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

1. GOVERNORATE

2. DISTRICT

3. SUBDISTRICT

4. LOCALITY

5. STRATUM NUMBER

6. CENSUS BLOCK NUMBER

7. JPFHS-II CLUSTER NUMBER

8. HOUSEHOLD NUMBER

9. URBAN/RURAL

URBAN=1
RURAL=2

10. AMMAN/LARGE CITY/MEDIUM CITY/TOWN/COUNTRYSIDE

AMMAN=1
MEDIUM CITY=2
SMALL CITY=3
TOWN=4
COUNTRYSIDE=5

AMMAN ALMOST 1,000,000
MEDIUM CITY (ZARQA, RUSSAIFA, IRBID, SALT, MADABA) 50,000 - 500,000
SMALL CITY 20,000 - 49,999
TOWN 5,000 - 19,999
COUNTRYSIDE LESS THAN 5,000

11. NAME OF HOUSEHOLD HEAD

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'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
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER____

NEXT VISIT
DATE
TIME

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR 1997
NAME
RESULT

TOTAL NUMBER OF VISITS

TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL NO. OF RESP. TO HOUSEHOLD SCHEDULE

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR

KEYED BY

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.

___

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?

______________

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

_____

4. RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

5. Did (NAME) stay here last night?

YES 1
NO 2

6. SEX: Is (NAME) male or female?

M 1
F 2

7. AGE: How old is (NAME)?

IN YEARS____

EDUCATION IF AGE 5 OR OLDER:

8. Has (NAME) ever been to school?

YES 1
NO 2

9. IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended? What is the highest grade (NAME) completed at that level?

GRADE____
LEVEL____

10. IF AGE LESS THAN 25 YEARS: Is (NAME) still in school?

YES 1
NO 2

PARENTAL SURVIVORSHIP AND RESIDENCE

11. Is (NAME)'s natural mother alive?

YES 1
NO 2
DK 8

12. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

___________

13. Is (NAME)'s natural father alive?

YES 1
NO 2
DK 8

14. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

___________

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

SINGLE/SIGNED CONTRACT 1
MARRIED 2
DIVORCED 3
WIDOWED 4
SEPARATED 5

ELIGIBILTY:

16. WOMAN: CIRCLE LINE NUMBER OF EVER MARRIED WOMEN AGE 15-49 YEARS WHO ARE USUAL RESIDENTS OR STAYED THERE ON THE NIGHT BEFORE INTERVIEW.

17. HUSBAND: CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INTERVIEW (I.E., MEN WHOSE WIVES ARE ELIGIBLE)

QUESTIONS AND FILTERS

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

PIPED WATER:
PIPED INTO
RESIDENCE/YARD/PLOT 11 (GO TO 20)
PUBLIC TAP 12
WELL WATER:
WELL IN RESIDENCE/YARD/PLOT 21 (GO TO 20)
PUBLIC WELL 22
SURFACE WATER:
SPRING 31
RIVER/STREAM 32
POND/LAKE 33
DAM 34
RAINWATER 41 (GO TO 20)
TANKER TRUCK 51 (GO TO 20)
BOTTLED WATER 61 (GO TO 20)
OTHER____________96

19. How long does it take to go there, get water, and come back?

MINUTES_______
ON PREMISIS 996

20. What kind of sewage system do you have in your house?

PUBLIC NETWORK 1
DUG HOLE 2
OTHER_______ 3
NO SEWAGE 4

20A. What kind of toilet facility does your household have?

FLUSH TOILET:
OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT TOILET/LATRINE:
TRADITIONAL PIT TOILET 21
NO FACILITY/BUSH/FIELD 31
OTHER___________ 96

21. Does your household have:

Electricity?
YES 1
NO 2
A radio?
RADIO THAT WORKS
YES 1
NO 2
A television?
TELEVISION THAT WORKS
YES 1
NO 2
A video?
YES 1
NO 2
A telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
An air conditioner?
YES 1
NO 2
Solar water heater?
YES 1
NO 2
Satelite dish?
YES 1
NO 2

22. How many rooms in your household are used for sleeping?

ROOMS_______

23. MAIN MATERIAL OF THE FLOOR.

RECORD OBSERVATION.

NATURAL FLOOR:
EARTH/SAND 11
RUDIMENTARY FLOOR:
WOOD PLANKS 21
FINISHED FLOOR:
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER_______ 96

24. Does any member of your household own:

A bicycle?
YES 1
NO 2
A motorcycle?
YES 1
NO 2
A private car?
YES 1
NO 2
A commercial car?
YES 1
NO 2
A pickup?
YES 1
NO 2
An agricultural tractor?
YES 1
NO 2
Another mode of transportation?
YES 1
NO 2

25. What type of salt is usually used for cooking in your household?
(ASK TO SEE SALT PACKAGE).

PACKAGED SALT (IODIZED) 1
PACKAGED SALT (NOT IODIZED) 2
OTHER_______ 6