IDENTIFICATION

PROVINCE/REGION

DISTRICT __

TEHSIL __

CLUSTER NUMBER __

HOUSEHOLD NUMBER __

HOUSEHOLD SELECTED FOR MEN INTERVIEW

PLACE NAME __

NAME OF HOUSEHOLD HEAD __

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS

DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT:
DATE
TIME

FINAL VISIT:
DAY
MONTH
YEAR
INT. NUMBER
RESULT*

TOTAL NUMBER OF VISITS __

LANGUAGE OF QUESTIONNAIRE: ENGLISH

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

SUPERVISOR:
NAME
DATE

FIELD EDITOR:
NAME
DATE

OFFICE EDITOR __

KEYED BY __

INTRODUCTION AND CONSENT

Asalum-o-Alaikum. My name is _________. I am working with National Institute of Population Studies. We are conduction a survey about health all over Pakistan. The information we collect will help the government to plan health services. Your household is 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.
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER: __________
DATE: ____

HOUSEHOLD SCHEDULE

Now I would like to ask you 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.
AFTER LISTING NAMES, RELATIONSHIP AND SEX FOR EACH PERSON, ASK Qs 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN AS QUESTIONS IN COLUMNS 5-25 FOR EACH PERSON.

2A) Just to make sure that I have a complete household 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 slept here last night, who have not been listed?

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

4) SEX
Is (NAME) male or female?

5) RESIDENCE
Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE
How old is (NAME)?
IF LESS THAN 1 YEAR, WRITE '00'.
IF AGE 95 YEARS OR MORE, WRITE '95'.

MARITAL STATUS IF AGE 15 YEARS OR OLDER
8) What is (NAME'S) current marital status?

9) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 YEARS WHO ARE MARRIED, WIDOWED, OR DIVORCED OR SEPARATED

10) CIRCLE LINE NUMBER OF ELIGIBLE MAN AGE 15-49 WHO ARE MARRIED, WIDOWED, OR DIVORCED OR SEPARATED

11) CIRCLE LINE NUMBER OF ELIGIBLE CHILD AGE 0-5

EDUCATION IF AGE 5 YEARS OR OLDER
12) Has (NAME) ever attended school?

13) What is the highest class (NAME) completed?

CURRENT SCHOOLING IF AGE 5-24 YEARS
14) Did (NAME) attend school/college/university at any time during the 2012 year?

15) During this year, which class/grade is (NAME) attending?

16) What is the main reason (NAME) is not attending school?
REASONS FOR NOT ATTENDING SCHOOL:

SURVIVORSHIP OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS
17) Is (NAME)'s natural mother alive?

18) Does (NAMES)'s natural 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'

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

20) Does (NAME) have NIC card or name entered onto a 'bay' form, or nothing at all?
IF NAME IS ON BAY FORM, HAS (NAME) BIRTH CERTIFICATE?
IF NEITHER NIC NOR NAME ON NIC BAY FORM, HAS (NAME) BIRTH CERTIFICATE?

MIGRATION FOR ALL USUAL MEMBERS
22) Was (NAME) born in this village/city?

23) From where did (NAME) move to this village/city?

24) In which year did (NAME) first move to this village/city?
(WRITE FOUR-DIGIT)

25) What was the primary reason for (NAME)'s move to this village/city?

OUT MIGRATION
26) Now I would like to ask you about members of this household who have lived here in the past 10 years but have since moved away.
Are there any members of your household who lived here in the past 10 years but who have since moved away?

27) LINE NO.

28) MIGRANTS
Please give me the names of the persons who are living outside of this household?
AFTER LISTING THE NAMES AND RECORDING THE SEX FOR EACH PERSON, ASK QUESTIONS 31-34 FOR EACH PERSON

29) Is (NAME) male or female?

30) In what month and year did (NAME) move away?

31) How old was (NAME) when he/she moved away?
IF AGE 95 OR MORE, RECORD '95'.
IF LESS THAN 1 YEAR OLD, RECORD '00'.

32) What was the main reason that (NAME) moved away?

33) Where has (NAME) travelled to?
IF OTHER CITY OF PAKISTAN, ASK FOR NAME OF CITY AND CODE. IF OTHER PART OF PAKISTAN, AS FOR NAME OF DISTRICT AND CODE. IF OTHER THAN PAKISTAN, ASK FOR NAME OF THE COUNTRY
CIRCLE THE CODES AS PROVIDED.

33A) TOTAL NUMBER OF MIGRANTS

34) CHECK THE IDENTIFICATION SECTION OF HOUSEHOLD QUESTIONNAIRE. IS HOUSEHOLD SELECTED FOR MEN INTERVIEW?

35) TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE
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 FEMALE RESPONDENTS ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. FOR EACH NON-ZERO NUMBER, THE IS THE COLUMN. YOU SHOULD GO TO THE CELL WHERE THE ROW AND COLUMN MEET; IS THE NUMBER OF THE SELECTED WOMAN FOR DOMESTIC VIOLENCE MODULE.
FOR EXAMPLE, IF THE HOUSEHOLD NUMBER IS '16', GO TO ROW '6'. IF THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 YEARS IN THE HOUSEHOLD, GO TO COLUMN '3'. FIND THE NUMBER IN THE BOX WHERE THE ROW MEETS THE COLUMN ('2'). NOW GO TO THE HOUSEHOLD SCHEDULE AND CIRCLE THE LINE NUMBER OF THE SELECTED WOMEN.
TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE MODULE:
HEADER FOR THE LEFT-HAND COLUMN: "LAST DIGIT OF THE HOUSEHOLD NUMBER (ROW)" (VALUES 0-9 BELOW THIS)
HEADER FOR TOP ROW OF TABLE: "TOTAL NUMBER OF ELIGIBLE WOMEN 15-49 YEARS IN THE HOUSEHOLD" (COLUMN)
COLUMNS WITH 1's, 2's, 3's, 4's, 5's, 6's, 7's, AND 8's FILL THE CELLS OF THE TABLE.

36) Line number of selected woman
(IF NO ELIGIBLE WOMAN WRITE '00' AND SKIP TO 101)

SECTION 1. HOUSEHOLD CHARACTERISTICS

101) How often does anyone smoke cigarette/huqa/berri or pipe inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

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

103) Where is that water source located?

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

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

106) What do you usually do to make the water safer to drink? Anything else>
CIRCLE ALL MENTIONED.

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

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

109) How many other households use this toilet facility?

110) Does your household have: for example:

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

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

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

114) MAIN MATERIAL OF THE FLOOR

115) MAIN MATERIAL OF THE ROOF

116) MAIN MATERIAL OF EXTERIOR WALLS

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

118) Does any member of this household own:

119) Does any member of this household own any agriculture land?

120) How many acres or kanals of agricultural land do members of this household own?
IF 95 OR MORE, RECORD '950' IN BOX.

121) Does this household own any livestock, herds, other farm animals, or poultry?

122) How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.

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

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

125) Who sprayed the dwelling?
(CIRCLE ALL MENTIONED)

126) Does your household have any mosquito nets that can be used while sleeping?

127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

128) How many of these mosquito nets are insecticide treated?
CIRCLE '0' IF ANSWER IS 'NONE'
IF 7 OR MORE, RECORD '7'

129) Do you usually soak the mosquito nets in a liquid that kill or repel mosquitos?

130) Generally, after how many months mosquito nets are soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'

131) Do you think that the use of insecticide treated nets can reduce the incidence of Malaria?

132) What else your household does to avoid mosquitos?

133) What do you do? Anything else?
(CIRCLE ALL MENTIONED)

134) Please show me where the members of your household most often was their hands?
OBSERVATION ONLY

135) OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING

136) OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANING AGENT

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5

201) CHECK IDENTIFICATION SECTION OF HOUSEHOLD QUESTIONNAIRE
HOUSEHOLD SELECTED FOR MEN INTERVIEW

202) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 203. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

203) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

204) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OR BIRTH FROM PREGNANCY HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: what is (NAME)'s birth date?

205) CHECK 204:
CHILD BORN IN JANUARY 2007 OR LATER?

206) WEIGHT IN KILOGRAMS

207) HEIGHT IN CENTIMETERS

208) MEASURED LYING DOWN OR STANDING UP?

209) GO BACK TO 204 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 210.

WEIGHT AND HEIGHT MEASUREMENT FOR ELIGIBLE WOMEN

210) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 211. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

211) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2

212) WEIGHT IN KILOGRAMS

213) HEIGHT IN CENTIMETERS

214) PREGNANCY STATUS:
CHECK 234 IN WOMAN'S QUESTIONNAIRE OT ASK:
Are you pregnant?

215) GO BACK TO 212 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END OF HOUSEHOLD QUESTIONNAIRE