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JORDAN POPULATION AND FAMILY HEALTH SURVEY 2002 HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

GROUP No:__

QUESTIONNAIRE No:___

GOVERNORATE:____

DISTRICT:____

SUBDISTRICT:____

LOCALITY:____

STRATUM:____

URBAN/RURAL:

Urban=1
Rural=2

BLOCK No:_____

BUILDING No:_____

HOUSING UNIT No:_____

CLUSTER No:_____

HOUSEHOLD No:____

TELEPHONE No (if available):____________

HOUSEHOLD SELECTED FOR ANEMIA TESTING (YES=1; NO=2)

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT

1 COMPLETED
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)

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 2002
NAME
RESULT

TOTAL NUMBER OF VISITS

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 three 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. SEX: Is (NAME) a 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

6A. DATE OF BIRTH: In what month and year was (NAME) born?

MONTH____
YEAR_______

IF DON'T KNOW MONTH: RECORD '98' FOR MONTHS
IF DON'T KNOW YEAR: RECORD '9998' FOR YEAR

7. AGE: How old is (NAME)?
(IF AGE=95+ RECORD 95)
(COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT)

IN YEARS______ (IF 15+ GO TO 14A)

PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD

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

YES 1
NO 2
DON'T KNOW 8

11. IF ALIVE: Does (NAME)'s natural mother live in this household?

IF YES: What is her name? RECORD MOTHER'S LINE NUMBER

_____

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

YES 1
NO 2
DON'T KNOW 3

13. IF ALIVE: Does (NAME)'s natural father live in this household?

IF YES: What is his name? RECORD FATHER'S LINE NUMBER

_____

IF AGE 6 YEARS OR OLDER:
14A. Has (NAME) ever attended school?

YES 1 (GO TO 14C)
NO 2

14B. Can (NAME) read and write?

YES 1 (GO TO 20A)
NO 2 (GO TO 20A)

14C. What is the highest level of school (NAME) has attended?

LEVEL___

CODING:

01 = OLD ELEMENTARY
02 = OLD PREPARATORY
03 = OLD SECONDARY
04 = NEW BASIC
05 = NEW SECONDARY
06 = INTERMEDIATE DIPLOMA
07 = UNIVERSITY
08 = HIGHER
98 = DON'T KNOW

14D. What is the highest grade (NAME) completed at that level?

GRADE___

CODING:

00 = LESS THAN 1 YEAR
98 = DON'T KNOW

IF AGE 6-24 YEARS:

14E. Did (NAME) attend school at any time during the last school year?

YES 1
NO 2

IF AGE 15 YEARS OR OLDER:

20A. What is (NAME)'s marital status?

NEVER MARRIED/SIGNED CONTRACT 1
MARRIED 2
DIVORCED 3
WIDOWED 4
SEPARATED 5

ELIGIBILITY

20B. CIRCLE LINE NUMBER OF ELIGIBLE WOMEN FOR THE INDIVIDUAL SURVEY (EVER MARRIED WOMEN AGE 15-49)

20C. CIRCLE LINE NUMBER OF NEVER MARRIED WOMEN AGE 15-49

20D. CIRCLE LINE NUMBER OF ALL CHILDREN BORN IN 1997 OR LATER, OR CHILDREN UNDER AGE 6 (IF DATE OF BIRTH IS UNKNOWN).

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

PIPED INTO DWELLING 11
PIPED INTO YARD 12
PUBLIC TAP 13
SPRING 21
RAINWATER 31
TANKER TRUCK 41
BOTTLED WATER 51
OTHER______ 96

21A. TYPE OF HOUSING UNIT (RECORD OBSERVATION)

APARTMENT 1
DAR 2
VILLA 3
HUT/BARRACK 4
OTHER___6

23. What kind of toilet facilities does your household have?

FLUSH TOILET:
OWN FLUSH TOILET 11
SHARED FLUSH TOILET 12
PIT TOILET/LATRINE:
OWN TRADITIONAL PIT 21
SHARED TRADITIONAL PIT TOILET 22
NO FACILITY 31
OTHER___ 96

23A. Is your house connected with:

Electricity?
YES 1
NO 2
Public Sewage?
YES 1
NO 2

25. Does your household have:

Radio or tape recorder?
YES 1
NO 2
Television?
YES 1
NO 2
Satellite?
YES 1
NO 2
Telephone?
YES 1
NO 2
Refrigerator?
YES 1
NO 2
Washing machine?
YES 1
NO 2
Solar heater?
YES 1
NO 2
Computer?
YES 1
NO 2
Internet access?
YES 1
NO 2

25A. Does your household have a mobile?
IF YES: How many?

NUMBER OF MOBLIES____

IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

25B. Does your household have a private car or pick-up?
IF YES: How many?

NUMBER OF CARS____

IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

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

ELECTRICITY 1
NATURAL GAS 2
KEROSENE 3
COAL, WOOD 4
OTHER_____6

27. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

NATURAL FLOOR:
EARTH/SAND 11
FINISHED FLOOR:
PARQUET OR POLISHED WOOD 21
VINYL 22
CERAMIC TILES 23
CEMENT 24
OTHER_____96

27A. How many rooms do you have in your house?

NUMBER OF ROOMS______

27B. How many rooms in your household are used for sleeping?

ROOMS FOR SLEEPING______

HEIGHT AND WEIGHT MEASUREMENT

CHECK COLUMNS (20B), (20C), AND (20D): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN BORN IN 1997 OR LATER, OR CHILDREN UNDER AGE 6 (IF DATE OF BIRTH UNKOWN).

36. LINE NO. FROM COL. (20B) OR (20C)

_____

37. NAME FROM COL. (2)

____________

38. AGE FROM COL. (7)

YEARS___

39. (CHILDREN BORN IN 1997 OR LATER ONLY) DATE OF BIRTH FROM COL. (6A) AND ASK DAY

MONTH____
DAY____
YEAR____

40. WEIGHT (KILOGRAMS)

_________

41. HEIGHT (CENTIMETERS)

_________

42. (CHILDREN BORN IN 1997 OR LATER ONLY) MEASURED LYING DOWN OR STANDING UP.

LYING 1
STANDING 2

43. RESULT

1=MEASURED
2=NOT PRESENT
3=REFUSED
6=OTHER

ANEMIA TEST

43A. CHECK COVER PAGE TO DETERMINE IF HOUSEHOLD IS INCLUDED IN THE SUBSAMPLE FOR ANEMIA TESTING:

YES (CONTINUE)
NO (END)

IF YES: CHECK COLUMNS (20B), (20C) AND (20D): RECORD THE LINE NUMBER (IN COL. 45), AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN BORN IN 1997 OR LATER, OR CHILDREN UNDER AGE 6 (IF DATE OF BIRTH UNKNOWN)

44. CHECK COLUMN (38):

AGE 15-17 (GO TO 45)
AGE 18-49 (GO TO 46)

45. LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

____

46. READ CONSENT STATEMENT TO WOMAN/PARENT/ RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)

GRANTED 1 (SIGN________)
REFUSED (GO TO NEXT LINE)

47. HEMOGLOBIN LEVEL (G/DL)

___.__

48. CHECK (20A): IF EVER MARRIED ASK FOR CURRENT PREGNANCY, IF SINGLE, CIRCLE '3'

YES 1
NO/DK 2
SINGLE 3

49. RESULT

1=MEASURED
2=NOT PRESENT
3=REFUSED
4=OTHER

50. CHECK 47 AND 48: NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT

ONE OR MORE (GIVE EACH WOMEN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH 51)
NONE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN AND END HOUSEHOLD INTERVIEW.)

51. We detected a low level of hemoglobin in (your blood/ the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, 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 hemoglobin in (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?

NAME(S) OF PERSON(S) WITH HEMOGLOBIN BELOW THE CUTOFF POINT:

__________

NAME OF PARENT/RESPONSIBLE ADULT

__________

AGREES TO REFERRAL?

YES 1
NO 2