HOUSEHOLD QUESTIONNAIRE

Survey Contents Confidential by Statistical Law

IDENTIFICATION

GOVERNORATE _____________

DISTRICT ___________

SUB-DISTRICT _____________

LOCALITY ____________

AREA ____________

NEIGHBORHOOD _____________

BLOCK NUMBER _____________

CLUSTER NUMBER ____

STRATUM NUMBER ___

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?

HOUSEHOLD SELECTED FOR HEALTH EXPENDITURE AND DOMESTIC VIOLENCE?

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

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
INT. NO.
RESULT*

TOTAL NUMBER OF VISITS

*RESULT CODES

TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
TOTAL ELIGIBLE MEN ____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

SUPERVISOR

NAME ______________
NUMBER ____________

OFFICE EDITOR
NUMBER ______________

INTRODUCTION AND CONSENT

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?

100) RECORD THE TIME.

HOUSEHOLD SCHEDULE

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?

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?

3) RELATIONSHIP TO HEAD OF THE HOUSE
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?

6) Did (NAME) stay here last night?

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

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?

8) MARITAL STATUS IF AGE 16 OR OLDER

What is (NAME)'s current marital status?

ELIGIBILITY

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?

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?

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?

17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

CURRENT/RECENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

18) Did (NAME) attend school at any time during the 2017-2018 school year?

19) During [this/that] school year, what level and grade [is/was] (NAME) attending?

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?

20A) SMOKING IF AGE 10 YEARS OR OLDER
Does (NAME) currently smoke?
IF YES: Does (NAME) smoke cigarettes, nargila, or both?

IF HOUSEHOLD SELECTED FOR HEALTH EXPENDITURE

INPATIENT

20B) In the last six months, was (NAME) admitted overnight to stay at a health facility?

20C) CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR INPATIENT MODULE.
CHECK COLUMN 20B: CODE '1' 'YES'

OUTPATIENT

20D) In the last four weeks, did (NAME) receive care from a health provider, or a pharmacy without staying overnight?

20E) CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR OUTPATIENT MODULE.
CHECK COLUMN 20D: CODE '1' 'YES'

HOUSEHOLD CHARACTERISTICS

100) TYPE OF HOUSING UNIT.
RECORD OBSERVATION.

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

102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

103) Where is that water source located?

104) How long does it take to go there, get water, and come back?

106) In the past two weeks, was the water from this source not available for at least one full day?

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

108) What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED.

109) What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

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

111) Including your own household, how many households use this toilet facility?

NO. OF HOUSEHOLDS

112) Where is this toilet facility located?

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

114) Is the cooking usually done in the house, in a separate building, or outdoors?

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

115A) Do you have an independent bathroom?

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:

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.

122C) CHECK 122A AND 122B:

122D) Do you have internet access at home?

123) Does any member of this household have a bank account?

123A) Does any member of the household have a credit card?

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?

142) OBSERVE MAIN METERIAL OF THE FLOOR OF THE SWELLING.
RECORD OBSERVATION.

143) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.

144) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.

DIABETES

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?

148) What is the name of the persons who have diabetes?
ENTER THE NAME AND LINE NUMBER OF EACH PERSON WITH DIABETES

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.

SELECTION OF ONE CHILD FOR CHILD DISCIPLINE (PAPER OPTION)

201) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR CHILD DISCIPLINE?

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:

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.

204) RANK NUMBER

205) HH LINE NUMBER

206) NAME FROM COLUMN 2

207) SEX FROM COLUMN 4

208) AGE FROM COLUMN 7

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.

210)

211) LINE NUMBER AND NAME OF THE CHILD SELECTED FOR CHILD DISCIPLINE (FROM 210)

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.

213) Do you believe that in order to bring up, raise or educate a child properly, the child needs to be physically punished?

SELECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS

300) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE?

300A) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE:

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)

INPATIENT HEALTH EXPENDITURES

400) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR HEALTH EXPENDITURE?

401) CHECK COLUMN 20C IN HOUSEHOLD SCHEDULE:

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?

406) What was the main reason for (NAME) to seek care this most recent time?

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

408) Did (NAME) stay overnight at a health facility another time in the last six months?

409) Where did (NAME) stay the next-to-last time (he/she) stayed overnight for health care?

410) What was the main reason for (NAME) to seek care this next-to-last time?

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

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?

413) Where did (NAME) stay the second-to-last time (he/she) stayed overnight for health care?

414) What was the main reason for (NAME) to seek care this second-to-last time?

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

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?

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?

419) What type of health insurance was used for (NAME)'s last stay overnight in a health facility?

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

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)

502A) LINE NUMBER AND NAME OF THE SELECTED OUTPATIENT (FROM 502)

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?

504) What was the main reason for (NAME) to seek care this most recent time?

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

505B) How much money was spent on:

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'

506) Did (NAME) get care another time in the last four weeks from a health provider, or pharmacy, without staying overnight?

506A) Where did (NAME) get care the next-to-last time without staying overnight?

506B) What was the main reason for (NAME) to seek care the next-to-last time?

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

506D) How much money was spent on:

506E) Did (NAME) get care another time in the last four weeks from a health provider, or pharmacy, without staying overnight?

506F) Where did (NAME) get care the second-to-last time without staying overnight?

506G) What was the main reason for (NAME) to seek care the second-to-last time?

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

506I) How much money was spent on:

506J) Did (NAME) get care another time in the last four weeks from a health provider, or pharmacy, without staying overnight?

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?

510) What type of health insurance was used when (NAME) got care the last time?

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'

512) RECORD THE TIME

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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