The Hashemite Kingdom of Jordan

Department of Statistics

Household Survey Directorate

9 June 2007

HOUSEHOLD QUESTIONNAIRE

Survey Contents Confidential by Statistical Law

IDENTIFICATION

GOVERNORATE:_____

DISTRICT:_____

SUB-DISTRICT:____

LOCALITY:_____

AREA:_____

SUB- AREA:______

STRATUM:______

URBAN/RURAL:

QUESTIONNAIRE NUMBER: ___

BLOCK NUMBER:_____

BUILDING NUMBER:______

HOUSING UNIT NUMBER:_____

CLUSTER NUMBER:_____

HOUSEHOLD NUMBER:____

TELEPHONE/ MOBILE NUMBER (if available) ______

HOUSEHOLD SELECTED FOR ANTHROPOMETRY AND ANEMIA TESTING

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE

INTERVIEWER VISITS

FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:

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 2007
INT. NUMBER__
RESULT:

TOTAL NUMBER OF VISITS__

TOTAL PERSONS IN HOUSHOLD___

TOTAL ELIGIBLE WOMEN____

LINE NUMBER OF RESPONDENT HOUSEHOLD QUESTIONNAIRE___

SUPERVISOR
NAME____
DATE____

FIELD EDITOR
NAME____
DATE____

OFFICE EDITOR__

KEYED BY___

INTRODUCTION AND CONSENT

Hello. My name is______________ and I am working with the Department of Statistics. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The interview usually takes between 10 and 15 minutes to complete.

As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer:______________________ Date: ____________________

HOUSEHOLD SCHEDULE

1) 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 NAMES AND RECORDING THE ERLATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON/

3) RELATIONSHIP TO THEAD OF HOUSEHOLD

What is the relationship of (NAME) to the head of the household?

4) SEX

Is (NAME) male or female?

RESIDENCE

5) Does (NAME) usually live here?

5A) Did (NAME) stay here last night?

6) DATE OF BIRTH

In what month and year was (NAME) born?

IF DON'T KNOW MONTH, RECORD 98' FOR MONTH.

IF DON'T KNOW YEAR, RECORD 9998' FOR YEAR.

6A) AGE

How old is (NAME)?

IF AGE IS 95 OR OLDER, RECORD 95.

COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT.

7) NATIONALITY

8) IF AGE 15 OR OLDER

MARITAL STATUS

What is (NAME'S) marital status?

ELIGIBILITY

9) INDIVIDUAL INTERVIEW

CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL SURVEY (EVER MARRIED WOMEN 15-49)

CHECK COVER PAGE IF THIS HOUSEHOLD IS SELECTED FOR AND ANEMIA

ANTRHOPOMETRY AND ANEMIA MEASUREMENTS

10) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

11) CIRCLE LINE NUMBER OF ALL CHILDREN BORN IN 2002 OR LATER, OR CHILD AGE 0-5 YEARS (IF DATE OF BIRTH NOT KNOWN) .

2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?

2B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

IF AGE 0-17 YEARS

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

12) Is (NAME)'s natural mother alive?

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

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

IF NO, RECORD '00'.

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

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

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

IF NO, RECORD '00'.

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

16A) Can (NAME) read and write?

17) What is the highest level of school (NAME) has attended?

17A) What is the highest grade (NAME) completed at that level?

IF AGE 5- 24 YEARS

18) Did (NAME) attend school at any time during the (2006- 2007) school year?

HOUSING UNIT AND HOUSEHOLD CHARACTERISTICS

100) TYPE OF HOUSING UNIT

RECORD OBSERVATION

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

101A) Is water normally available all day from this source?

101B) In the last two weeks, was water unavailable for an entire day or longer?

106) Do you do anything to the water to make it safer to drink?

107) What do you usually do to make the water safer to drink?

Anything else?
RECORD ALL MENTIONED.

108) What kind of toilet facility do members of your household usually use?

IF FLUSH TOILET: Is your toilet connected to a public sewer system, a septic tank, a pit latrine or somewhere else?

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

110A) Is your house connected with electricity?

110B) Does your household have a bed or sofa bed?

IF YES: How many beds or sofa beds does your household have?

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

111) Does your household have:

A radio/ tape recorder?

A television?

Satellite?

A land telephone?

A refrigerator?

A washing machine?

Solar heater?

Air conditioner?

Fan?

Water cooler?

Microwave?

Digital camera?

111A) Does your household have a computer?

IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

111B) Does your household have a mobile?

IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

111C) CHECK 111A AND 111B:

111D) Do you have internet access at home?

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

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

116A) Do you have an independent bathroom?

117) MAIN MATERIAL OF THE FLOOR.

119) MAIN MATERIAL OF THE EXTERIOR WALLS/
RECORD OBSERVATION.

119A) How many rooms do you have in your house?

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

120A) Does your household own a private car or pickup?

IF YES: How many?
IF NO, RECORD '0'. IF 7 OR MORE, RECORD 7.

126A) Does any member of this household have a credit card?

USE THIS TABLE WHEN:
1) The household is selected for the domestic violence module
AND
2) There is more than one eligible women in the household

RANDOM NUMBER TABLE FOR SELECTIONN OF WOMAN AS RESONDENT TO DOMESTIC VIOLENCE MODULE

CHECK THE HOUSEHOLD NUMBER ON THE COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE.

THIS IS THE NUMBER REOW TO SELECT.

FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THAT NUMBER.

THIS IS THE POSITION NUMBER OF THE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE MODULE.

IN COLUMN 9 PF THE HOUSEHOLD SCHEDULE, DRAW A BOX AROUND THE LINE NUMBER OF THE ELIGIBLE WOMAN IN THAT POSITION.

EXAMPLE:
IF THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS 6, AND THERE ARE 3 ELIGIBLE WOMEN, THE NUMBER IN THE BOX WHERE ROW 6 AND COLUMN 3 MEET IS 2, THAT MEANS THAT THE 2ND ELIGIBLE WOMAN WILL BE SELECTED FOR THE MODULE.

NOW SUPPOSE THE THREE ELIGIBLE WOMEN'S LINE NUMBERS ARE '02', '03', AND '07', THEN THE 2ND ELIGIBLE WOMAN (LINE NUMBER '03') IS SELECTED FOR THE MODULE.

HEADER FOR LEFT-HAND COLUMN: "HOUSEHOLD NUMBER" (VALUES 0-15 BELOW THIS) (ROW)

HEADER FOR TOP ROW OF TABLE: TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)

COLUMNS WITH 1'S, 2'S, 3'S, 4'S, 5'S, AND 6'S FILL THE CELLS OF THE TABLE.

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENTS FOR CHILDREN AGE 0-5

201) CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 208 AND FOR THE ANEMIA PROCEDURE IN 213.

202) LINE NUMBER FROM COLUMN 11

NAME FROM COLUMN 2

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTROY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?

204) CHECK 203: CHILD BORN IN JANUARY 2002 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

208) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

209) CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOS MONTHS?

210) LINE NUMBER OF PARENT/ OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1)
RECORD '00' IF NOT LISTED

211) READ CONSENT STATEMENT TO PARENT/ OTHER ADULT RESPONSIBLE FOR CHILD.
CIRCLE CODE AND SIGN.

212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

213) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT

214) GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 215.

CONSENT STATEMENT FOR ANEMIA FOR CHILDREN

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

We request that all children born in 2002 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept confidential.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the anemia test?

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT TESTING FOR WOMEN AGE 15- 49

215) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 216. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 219 AND FOR THE ANEMIA TEST PROCEDURE IN 227

216) LINE NUMBER (COLUMN 10)

NAME (COLUMN 2)

217) WEIGHT IN KILOGRAMS

218) HEIGHT IN CENTIMETERS

219) RESULT OF WEIGHT AND HEIGHT MEASUREMENT

220) AGE: CHECK COLUMN 7

221) MARITAL STATUS: CHECK COLUMN 8.

222) FROM COLUMN 1 RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

223) READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 222 BEFORE ASKING RESPONDENT'S CONSENT.

CONSENT STATEMENT FOR ANEMIA TEST

READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 223 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES/

FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 222) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 223 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.

As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.

For the anemia testing, we will need a few drops of blood from a finger. The equipment used in taking blood is clean and completely safe. It has never been used before and will be thrown away after each test.

The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept confidential.

Do you have any questions?

You can say yes to the test, or you can say no. It is up to you to decide.
Will you (allow NAME OF ADOLESCENT to) take the anemia test?

224) PREGNANCY STATUS: CHECK COLUMN 8:

IF EVER MARRIED (CODES 2-5), ASK: Are you pregnant?

IF NEVER MARRIED (CODE 1), CIRCLE '3'

225) CHECK 223 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST.

A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 227 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.

226) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET

227) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.