The Hashemite Kingdom of Jordan
JORDAN POPULATION AND FAMILY HEALTH SURVEY 2017
HOUSEHOLD QUESTIONNAIRE
Survey Contents Confidential by Statistical Law
GOVERNORATE _____________
DISTRICT ___________
SUB-DISTRICT _____________
LOCALITY ____________
AREA ____________
NEIGHBORHOOD _____________
BLOCK NUMBER _____________
CLUSTER NUMBER ____
STRATUM NUMBER ___
RURAL 2
BUILDING NUMBER ______________
HOUSING UNIT NUMBER ______________
HOUSEHOLD NUMBER _____________
NAME OF HOUSEHOLD HEAD _________________________________________
TELEPHONE/MOBILE NUMBER (IF AVAILABLE) ________________________
HOUSEHOLD SELECTED FOR CHILD DISCIPLINE, CHILD DEVELOPMENT, AND BIOMARKER FOR WOMEN?
NO 2
HOUSEHOLD SELECTED FOR HEALTH EXPENDITURE AND DOMESTIC VIOLENCE?
NO 2
HOUSEHOLD SELECTED FOR MAN'S SURVEY?
NO 2
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
INT. NO.
RESULT*
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) _________________
TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
NAME ______________
NUMBER ____________
OFFICE EDITOR
NUMBER ______________
Hello. My name is _________________________________. I am working with the Department of Statistics. We are conducting a survey about health all over Jordan. The information we collect 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 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. 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.
In case you need more information about the survey, you may contact the person listed on this card.
GIVE CARD WITH CONTACT INFORMATION.
Do you have any questions?
RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES ______
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 NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON. ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.
2A) Just to make sure that I have a complete listing: are there any other people such as small children or infants that we have not listed?
NO
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?
NO
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
3) RELATIONSHIP TO HEAD OF THE HOUSE
What is the relationship of (NAME) to the head of the household?
02 = WIFE OR HUSBAND
03 = SON OR DAUGHTER
04 = STEPSON OR STEPDAUGHTER
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = GRAND FATHER/MOTHER
10 = OTHER RELATIVE
11 = ADOPTED/FOSTER CHILD
12 = NOT RELATED
98 = DON'T KNOW
4) SEX
Is (NAME) male or female?
FEMALE 2
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
6A) 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
YEAR _____
7) AGE
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.
COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT.
7A) NATIONALITY
What is (NAME)'s nationality?
2 = EGYPTIAN
3 = SYRIAN
4 = IRAQUI
5 = OTHER ARAB
6 = NOT ARAB
8 = DON'T KNOW
8) MARITAL STATUS IF AGE 16 OR OLDER
What is (NAME)'s current marital status?
2 = MARRIED
3 = DIVORCED
4 = WIDOWED
5 = SEPARATED
9) CIRCLE LINE NUMBER OF EVER MARRIED WOMEN AGE 15-49
9A) CIRCLE LINE NUMBER OF ALL WOMEN 15-49
10) IF HOUSEHOLD SELECTED FOR MAN'S SURVEY, CIRCLE LINE NUMBER OF ALL MEN AGE 15-59
11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS, IF AGE 0-17 YEARS
12) Is (NAME)'s natural mother alive?
NO 2 (GO TO 14)
DK 8 (GO TO 140
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: '00'.
14) Is (NAME)'s natural father alive?
NO 2 (GO TO 16)
DK 8 (GO TO 16)
15) Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What was his name?
RECORD FATHER'S LINE NUMBER
IF NO: RECORD '00'.
EVER ATTENDED SCHOOL IF AGE 8 YEARS OR OLDER
16) Has (NAME) ever attended school?
NO 2 (GO TO 20A)
17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
GRADE____
02 = OLD PREPARATORY
03 = OLD SECONDARY
3 = HIGHER
05 = NEW SECONDARY
06 = INTERMEDIATE DIPLOMA
07 = BACHELOR
08 = HIGHER EDUCATION
98 = DON'T KNOW
98 = DON'T KNOW
CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS
18) Did (NAME) attend school at any time during the 2017-2018 school year?
NO 2 (GO TO 20A)
19) During [this/that] school year, what level and grade [is/was] (NAME) attending?
GRADE____
02 = OLD PREPARATORY
03 = OLD SECONDARY
3 = HIGHER
05 = NEW SECONDARY
06 = INTERMEDIATE DIPLOMA
07 = BACHELOR
08 = HIGHER EDUCATION
98 = DON'T KNOW
98 = DON'T KNOW
20) BIRTH REGISTRATION IF AGE 0-4 YEARS
Does (NAME) have a birth certificate?
IF NO PROBE: Has (NAME)'s birth ever been registered with the civil authority?
2 = REGISTERED
3 = NEITHER
8 = DON'T KNOW
20A) SMOKING IF AGE 10 YEARS OR OLDER
Does (NAME) currently smoke?
IF YES: Does (NAME) smoke cigarettes, nargila, or both?
2 = YES NARGILA
3 = YES BOTH
4 = NO
8 = DON'T KNOW
IF HOUSEHOLD SELECTED FOR HEALTH EXPENDITURE
INPATIENT
20B) In the last six months, was (NAME) admitted overnight to stay at a health facility?
NO 2 (GO TO 20D)
DON'T KNOW (GO TO 20D)
20C) CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR INPATIENT MODULE.
CHECK COLUMN 20B: CODE '1' 'YES'
20D) In the last four weeks, did (NAME) receive care from a health provider, or a pharmacy without staying overnight?
NO 2 (NEXT LINE)
DK 8 (NEXT LINE)
20E) CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR OUTPATIENT MODULE.
CHECK COLUMN 20D: CODE '1' 'YES'
100) TYPE OF HOUSING UNIT.
RECORD OBSERVATION.
DAR 2
VILLA 3
HUT/BARRACK 4
OTHER(SPECIFY) ___________ 6
101) What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 106)
SPRING 21 (SKIP TO 103)
RAINWATER 31 (SKIP TO 103)
TANKER TRUCK 41 (SKIP TO 103)
BOTTLED WATER 51
OTHER (SPECIFY) ______________
102) What is the main source of water used by your household for other purposes such as cooking and handwashing?
PIPED TO YARD/PLOT 12 (SKIP TO 106)
SPRING 21
RAINWATER 31
TANKER TRUCK 41
BOTTLED WATER 51 (SKIP TP 109)
OTHER(SPECIFY) ___________ 96
103) Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 106)
ELSEWHERE 3
104) How long does it take to go there, get water, and come back?
DON'T KNOW 998
106) In the past two weeks, was the water from this source not available for at least one full day?
NO 2
DON'T KNOW 8
107) Do you do anything to the water to make it safer to drink?
NO 2 (SKIP TO 109)
DON'T KNOW 8 (SKIP TO 109)
108) What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED.
ADD BLEACH/CHLORINE B
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC) C
OTHER (SPECIFY) _____________ X
DON'T KNOW Z
109) What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.
FLUSH TO PIT LATRINE 12
FLUSH TO SOMEWHERE ELSE 13
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
OTHER (SPECIFY) _________________ 96
110) Do you share this toilet facility with other households?
NO 2 (SKIP TO 112)
111) Including your own household, how many households use this toilet facility?
NO. OF HOUSEHOLDS
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
112) Where is this toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE 3
113) What type of fuel does your household mainly use for cooking?
NATURAL GAS 02
KEROSENE 03
COAL, WOOD 04
NO FOOD COOKER IN HOUSEHOLD 95 (SKIP TO 115A)
OTHER (SPECIFY) _____________ 96
114) Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (SKIP TO 115A)
OUTDOORS 3 (SKIP TO 115A)
OTHER (SPECIFY) ________________ 6 (SKIP TO 115A)
115) Do you have a separate room which is used as a kitchen?
NO 2
115A) Do you have an independent bathroom?
NO 2
115B) How many rooms do you have in your house?
116) How many rooms in the household are used for sleeping?
120A) 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.
121) Does your household have:
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
121A) Does your household own a private car or pickup?
IF YES: How many?
IF NONE, RECORD '0'
IF 7 OR MORE, RECORD 7
122A) Does any member of your household have a computer or tablet?
IF YES: How many computers/tablets do you have in total in your household?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
122B) Does any member of your household have a mobile or smart phone?
IF YES: How many mobile/smart phones do you have in total in your household?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
122A AND 122B = 0 (SKIP TO 123)
122D) Do you have internet access at home?
NO 2
123) Does any member of this household have a bank account?
NO 2 (SKIP TO 124)
123A) Does any member of the household have a credit card?
NO 2
124) How often does anyone smoke cigarette/nargila inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?
WEEKLY 2
MONTHLY 3
LESS OFTEN THAN ONCE A MONTH 4
NEVER 5
142) OBSERVE MAIN METERIAL OF THE FLOOR OF THE SWELLING.
RECORD OBSERVATION.
TILES 32
MARBLE/CERAMIC TILES 33
CEMENT 34
143) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
MUD BRICKS WITH STONES 22
144) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
MUD BRICKS WITH STONES 22
CUT STONES 32
CUT STONES AND CONCRETE 33
CONCRETE 34
147) Now, I would like to ask you some questions about the health of your household's members.
Has any member of your household ever been told by a doctor or other health worker that he/she has diabetes?
NO 2 (SKIP TO 201)
DON'T KNOW 8 (SKIP TO 201)
148) What is the name of the persons who have diabetes?
ENTER THE NAME AND LINE NUMBER OF EACH PERSON WITH DIABETES
LINE NUMBER ___________
149) How long ago was [NAME] diagnosed with diabetes?
IF LESS THAN 12 MONTHS, ANSWER MUST BE RECORDED IN MOTHS.
IF 12 MONTHS (1 YEAR) OR MORE. ANSWER MUST BE RECORDED IN YEARS.
YEARS AGO 2 _________
DON'T KNOW 998
SELECTION OF ONE CHILD FOR CHILD DISCIPLINE (PAPER OPTION)
201) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR CHILD DISCIPLINE?
HOUSEHOLD NOT SELECTED FOR CHILD DISCIPLINE (GO TO 300)
202) CHECK COLUMN 7 IN THE LIST OF HOUSEHOLD MEMBERS AND WRITE THE TOTAL NUMBER OF CHILDREN AGE 1-14 YEARS.
203) CHECK NUMBER OF CHILDREN 1-14 YEARS IN 202:
ONE (SKIP TO 210 AND RECORD THE RANK NUMBER AS '1', ENTER THE LINE NUMBER, CHILD'S NAME AND AGE)
TWO OR MORE (CONTINUE)
203A) LIST EACH OF THE CHILDREN AGE 2-14 YEARS BELOW IN THE ORDER THEY APPEAR IN THE LIST OF HOUSEHOLD MEMBERS. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS OUTSIDE OF THE AGE RANGE 1-14 YEARS. RECORD THE LINE NUMBER, NAME, SEX, AND AGE FOR EACH CHILD.
FEMALE 2
209) LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE CHILDREN 202 ON THE PREVIOUS PAGE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE RANK NUMBER OF THE CHILD SELECTED FOR THE CHILD DISCIPLE QUESTIONS FROM THE BOX OF ELIGIBLE CHILDREN IN 203A. WRITE THE NAME, LINE NUMBER, AND RANK NUMBER OF THE SELECTED CHILD IN THE SPACE BELOW THE TABLE.
EXAMPLE: THE HOUSEHOLD NUMBER IS '716' AND 202 SHOWS THAT THERE ARE THREE ELIGIBLE CHILDREN AGE 1-14 IN THE HOUSEHOLD. SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE CHILDREN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO 203A AND FIND THE SECOND CHILD. WRITE THE NAME, LINE NUMBER, AND RANK NUMBER OF THE CHILD IN THE SPACE BELOW THE TABLE.
TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 1-14 IN HOUSEHOLD FROM 202 1-8+
HH LINE NUMBER OF SELECTED CHILD ____
RANK NUMBER OF SELECTED CHILD ____
AGE OF SELECTED CHILD ____
211) LINE NUMBER AND NAME OF THE CHILD SELECTED FOR CHILD DISCIPLINE (FROM 210)
NAME ________________
212) Adults use certain ways to teach children the right behavior or to address a behavior problem. I will read various methods that are used. Please tell me if you or anyone else in the household has used this method with (NAME) in the past month.
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
213) Do you believe that in order to bring up, raise or educate a child properly, the child needs to be physically punished?
NO 2 (SKIP TO 512)
DON'T KNOW/ NO OPINION 8 (SKIP TO 512)
SELECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS
300) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE?
HOUSEHOLD NOT SELECTED FOR DOMESTIC VIOLENCE (SKIP TO 512)
300A) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE:
ONLY ONE EVER-MARRIED WOMEN AGE 15-49 (GO TO 301)
NO EVER-MARRIED WOMEN AGE 15-49 (GO TO 401)
LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ATE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S.
LAST DIGIT OF THE HOUSEHOLD NUMBER 0-9
TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD FROM COLUMN 9
301)
HH LINE NUMBER OF SELECTED WOMAN ___________
400) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR HEALTH EXPENDITURE?
HOUSEHOLD NOT SELECTED FOR HEALTH EXPENDITURE (SKIP TO 512)
401) CHECK COLUMN 20C IN HOUSEHOLD SCHEDULE:
NO INPATIENTS (SKIP TO 501)
402) CHECK COLUMN 20C IN HOUSEHOLD SCHEDULE: ENTER THE LINE NUMBER OR EACH HOUSEHOLD MEMBER WHO WAS AN IMPATIENT. THEN ASK: Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last six months. (IF THERE ARE MORE THAN 3 INPATIENTS, USE ADDITIONAL QUESTIONNAIRE).
403) LINE NUMBER FROM COLUMN 20C IN HOUSEHOLD SCHEDULE
INPATIENT
404) NAME FROM COLUMN 2 IN HOUSEHOLD SCHEDULE
405) Where did (NAME) most recently stay overnight for health care?
UNIVERSITY HOSPITAL 22
ROYAL/MILITARY/HOSPITAL/MED. CENTER 23
OTHER PUBLIC SECTOR (SPECIFY) ______________________ 26
OTHER PRIVATE MED. SECTOR (SPECIFY) ____________________ 36
406) What was the main reason for (NAME) to seek care this most recent time?
NEW BORN/CHILD CARE 02
CANCER 03
HEART DISEASES 04
DIABETES 05
OTHER ILLNESS 06
ACCIDENT/INJURY 07
OTHER (SPECIFY) _____________________ 96
DON'T KNOW 98
407) How much money was spent on treatment and services (NAME) received during the most recent overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.
IF 99993 JD OR MORE, RECORD 99993
NO COST/ FREE 00000
IN KIND ONLY 99995
DON'T KNOW 99998
408) Did (NAME) stay overnight at a health facility another time in the last six months?
NO 2 (GO TO 418)
409) Where did (NAME) stay the next-to-last time (he/she) stayed overnight for health care?
UNIVERSITY HOSPITAL 22
ROYAL/MILITARY/HOSPITAL/MED. CENTER 23
OTHER PUBLIC SECTOR (SPECIFY) ______________________ 26
OTHER PRIVATE MED. SECTOR (SPECIFY) ____________________ 36
410) What was the main reason for (NAME) to seek care this next-to-last time?
NEW BORN/CHILD CARE 02
CANCER 03
HEART DISEASES 04
DIABETES 05
OTHER ILLNESS 06
ACCIDENT/INJURY 07
OTHER (SPECIFY) _____________________ 96
DON'T KNOW 98
411) How much money was spent on treatment and services (NAME) received during the next-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.
IF 99993 JD OR MORE, RECORD 99993
NO COST/ FREE 00000
IN KIND ONLY 99995
DON'T KNOW 99998
412) Besides the two stays you have told me about, did (NAME) stay overnight at a health facility another time in the last six months?
NO 2 (GO TO 418)
413) Where did (NAME) stay the second-to-last time (he/she) stayed overnight for health care?
UNIVERSITY HOSPITAL 22
ROYAL/MILITARY/HOSPITAL/MED. CENTER 23
OTHER PUBLIC SECTOR (SPECIFY) ______________________ 26
OTHER PRIVATE MED. SECTOR (SPECIFY) ____________________ 36
414) What was the main reason for (NAME) to seek care this second-to-last time?
NEW BORN/CHILD CARE 02
CANCER 03
HEART DISEASES 04
DIABETES 05
OTHER ILLNESS 06
ACCIDENT/INJURY 07
OTHER (SPECIFY) _____________________ 96
DON'T KNOW 98
415) How much money was spent on treatment and services (NAME) received during the second-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory tests, drugs, or other items.
IF 99993 JD OR MORE, RECORD 99993
NO COST/ FREE 00000
IN KIND ONLY 99995
DON'T KNOW 99998
416) Besides the three stays you have told me about, did (NAME) stay overnight at a health facility another time in the last six months?
NO 2 (GO TO 418)
417) In total, how many times did (NAME) stay overnight in a health facility in the last six months?
418) In (NAME) covered by any health insurance or an exemption?
YES, EXEMPTION 2 (SKIP TO 420)
NO 3 (SKIP TO 420)
DON'T KNOW 8 (SKIP TO 420)
419) What type of health insurance was used for (NAME)'s last stay overnight in a health facility?
ROYAL/MILITARY HEALTH INSURANCE 02
UNIVERSITY HOPITAL INSURANCE 03
UNRWA INSURANCE 04
UNHCR INSURANCE 05
NGO INSURANCE 06
PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE 07
PRIVATE SECTOR INSURANCE 08
OTHER 96
NONE 95
DON'T KNOW 98
420) GO BACK TO 405 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 501
SELECTION FOR OUTPATIENT HEALTH EXPENDITURES (PAPER OPTION)
501) CHECK COLUMN 20E
ONLY ONE ELIGIBLE OUTPATIENT (SKIP TO 502)
NO ELIGIBLE OUTPATIENTS (SKIP TO 512)
TABLE FOR SELECTION OF OUTPATIENT WHO PAID FOR CARE THE LAST TIME SOUGHT CARE IN THE LAST FOUR WEEKS
LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE OUTPATIENTS (COLUMN 20E) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE PERSON SELECTED FOR THE OUTPATIENT QUESTIONS FROM THE LIST OF ELIGIBLE OUTPATIENTS IN COLUMN 20E OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q502.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 20E SHOWS THAT THERE ATE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND OUTPATIENT WHO IS ELIGIBLE FOR THE OUTPATIENT QUESTIONS (LINE NUMBER '04' IN THIS EXAMPLE). WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q502.
LAST DIGIT OF THE HOUSEHOLD NUMBER 0-9
TOTAL NUMBER OF ELIGIBLE OUTPATIENTS IN HOUSEHOLD SCHEDULE COLUMN 20E FROM 1-8
502)
HH LINE NUMBER OF SELECTED OUTPATIENT __
502A) LINE NUMBER AND NAME OF THE SELECTED OUTPATIENT (FROM 502)
NAME _____________
503) Now I would like to ask some questions about health care that (NAME) received in the last four weeks, without having to stay overnight. Where did (NAME) get care most recently without staying overnight?
UNIVERSITY HOSPITAL 22
ROYAL/MILITARY/HOSPITAL/MED. CENTER 23
GOVERNMENT HEALTH CENTER 24
MOBILE CLINIC 25
FIELDWORKER 26
OTHER PUBLIC SECTOR (SPECIFY) ______________________ 27
PHARMACY 32
PRIVATE DOCTOR 33
MOBILE CLINIC 34
UNRWA HEALTH CENTER 35
UNHCR/NGO 36
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____________________ 37
504) What was the main reason for (NAME) to seek care this most recent time?
ANTENATAL CARE/DELIVERY/POSTNATAL CARE 02
NEW BORN/CHILD CARE 03
FEVER 04
DIARRHEA 05
HEART DISEASE 06
HYPERTENSION 07
DIABETES 08
OTHER ILLNESS 09
CHECK-UP/PREVENTIVE CARE 10
VACCINATION 11
ACCIDENT/INJURY 12
OTHER (SPECIFY) ___________________96
505A) How much money was spent on treatment and services (NAME) received from (NAME OF PROVIDER IN 503)? Please include the consulting fee and any expenses for other items including drugs and tests, transportation, and other items.
IF 9993 JD OR MORE, RECORD 9993
NO COST/ FREE 00000 (SKIP TO 506)
IN KIND ONLY 99995 (SKIP TO 506)
DON'T KNOW 99998 (SKIP TO 506)
505B) How much money was spent on:
b) Medications
c) Laboratory cost
d) X-ray (MRI, Scanner, ECG, Mammogram, etc.)
e) Transportation
f) Other
IF NO FREE, RECORD '0000'
IF NO SPECIFIC EXPENSE, RECORD '9994'
IF 993 JD OR MORE, RECORD 9993
IF IN KIND, RECORD '9995'
IF DON'T KNOW, RECORD '9998'
COST b) ____
COST c) ____
COST d) ____
COST e) ____
COST f) ____
506) Did (NAME) get care another time in the last four weeks from a health provider, or pharmacy, without staying overnight?
NO 2 (GO TO 509)
506A) Where did (NAME) get care the next-to-last time without staying overnight?
UNIVERSITY HOSPITAL 22
ROYAL/MILITARY/HOSPITAL/MED. CENTER 23
GOVERNMENT HEALTH CENTER 24
MOBILE CLINIC 25
FIELDWORKER 26
OTHER PUBLIC SECTOR (SPECIFY) ______________________ 27
PHARMACY 32
PRIVATE DOCTOR 33
MOBILE CLINIC 34
UNRWA HEALTH CENTER 35
UNHCR/NGO 36
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____________________ 37
506B) What was the main reason for (NAME) to seek care the next-to-last time?
ANTENATAL CARE/DELIVERY/POSTNATAL CARE 02
NEW BORN/CHILD CARE 03
FEVER 04
DIARRHEA 05
HEART DISEASE 06
HYPERTENSION 07
DIABETES 08
OTHER ILLNESS 09
CHECK-UP/PREVENTIVE CARE 10
VACCINATION 11
ACCIDENT/INJURY 12
OTHER (SPECIFY) ___________________96
506C) How much money was spent on treatment and services (NAME) received from (NAME OF PROVIDER IN 503)? Please include the consulting fee and any expenses for other items including drugs and tests, transportation, and other items.
IF 9993 JD OR MORE, RECORD 9993
NO COST/ FREE 00000 (SKIP TO 506E)
IN KIND ONLY 99995 (SKIP TO 506E)
DON'T KNOW 99998 (SKIP TO 506E)
506D) How much money was spent on:
b) Medications
c) Laboratory cost
d) X-ray (MRI, Scanner, ECG, Mammogram, etc.)
e) Transportation
f) Other
IF NO FREE, RECORD '0000'
IF NO SPECIFIC EXPENSE, RECORD '9994'
IF 993 JD OR MORE, RECORD 9993
IF IN KIND, RECORD '9995'
IF DON'T KNOW, RECORD '9998'
COST b) ____
COST c) ____
COST d) ____
COST e) ____
COST f) ____
506E) Did (NAME) get care another time in the last four weeks from a health provider, or pharmacy, without staying overnight?
NO 2 (GO TO 509)
506F) Where did (NAME) get care the second-to-last time without staying overnight?
UNIVERSITY HOSPITAL 22
ROYAL/MILITARY/HOSPITAL/MED. CENTER 23
GOVERNMENT HEALTH CENTER 24
MOBILE CLINIC 25
FIELDWORKER 26
OTHER PUBLIC SECTOR (SPECIFY) ______________________ 27
PHARMACY 32
PRIVATE DOCTOR 33
MOBILE CLINIC 34
UNRWA HEALTH CENTER 35
UNHCR/NGO 36
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) ____________________ 37
506G) What was the main reason for (NAME) to seek care the second-to-last time?
ANTENATAL CARE/DELIVERY/POSTNATAL CARE 02
NEW BORN/CHILD CARE 03
FEVER 04
DIARRHEA 05
HEART DISEASE 06
HYPERTENSION 07
DIABETES 08
OTHER ILLNESS 09
CHECK-UP/PREVENTIVE CARE 10
VACCINATION 11
ACCIDENT/INJURY 12
OTHER (SPECIFY) ___________________96
506H) How much money was spent on treatment and services (NAME) received from (NAME OF PROVIDER IN 503)? Please include the consulting fee and any expenses for other items including drugs and tests, transportation, and other items.
IF 9993 JD OR MORE, RECORD 9993
NO COST/ FREE 00000 (SKIP TO 506J)
IN KIND ONLY 99995 (SKIP TO 506J)
DON'T KNOW 99998 (SKIP TO 506J)
506I) How much money was spent on:
b) Medications
c) Laboratory cost
d) X-ray (MRI, Scanner, ECG, Mammogram, etc.)
e) Transportation
f) Other
IF NO FREE, RECORD '0000'
IF NO SPECIFIC EXPENSE, RECORD '9994'
IF 993 JD OR MORE, RECORD 9993
IF IN KIND, RECORD '9995'
IF DON'T KNOW, RECORD '9998'
COST b) ____
COST c) ____
COST d) ____
COST e) ____
COST f) ____
506J) Did (NAME) get care another time in the last four weeks from a health provider, or pharmacy, without staying overnight?
NO 2 (GO TO 509)
507) How many other times did (NAME) get care in the last four weeks?
508) How many times was money spent?
509) Is (NAME) covered by any health insurance or an exemption?
YES, EXEMPTION 2 (SKIP TO 511)
NO 3 (SKIP TO 511)
DON'T KNOW 8 (SKIP TO 511)
510) What type of health insurance was used when (NAME) got care the last time?
ROYAL/MILITARY HEALTH INSURANCE 02
UNIVERSITY HOPITAL INSURANCE 03
UNRWA INSURANCE 04
UNHCR INSURANCE 05
NGO INSURANCE 06
PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE 07
PRIVATE SECTOR INSURANCE 08
OTHER 96
NONE 95
DON'T KNOW 98
511) Sometimes people buy vitamins, medicines, and herbal remedies without consulting with a health provider, pharmacy, or traditional healer. They may also buy other health-related items such as band-aids/plasters, thermometers, or other medical devices, and so on without a consultation. In the last four weeks, how much money was spent on these types of health-related items for members of your household?
IF 9993 JD OR MORE, RECORD '9993'
NO COST/FREE 0000
IN KIND ONLY 9995
DON'T KNOW 9998
MINUTES ___
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW:
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COMMENTS ON SPECIFIC QUESTIONS:
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ANY OTHER COMMENTS:
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SUPERVISOR'S OBSERVATIONS:
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EDITOR'S OBSERVATIONS:
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