PAKISTAN
NATIONAL INSTITUTE OF POPULATION STUDIES

IDENTIFICATION

PROVINCE/REGION

DISTRICT ______

TEHSIL ________

NAME OF HOUSEHOLD HEAD _______

CLUSTER NUMBER _______

HOUSEHOLD NUMBER _______

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR DV?

INTERVIEWER VISITS

FIRST VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______

NEXT VISIT DATE _____
TIME ______

SECOND VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______

NEXT VISIT DATE _____
TIME ______

THIRD VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______

NEXT VISIT DATE _____
TIME ______

FINAL VISIT
DAY _____
MONTH ______
YEAR _____
INT. NO. _______
RESULT* _______

TOTAL NUMBER OF VISITS _________

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN ______
TOTAL ELIGIBLE MEN _______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE OF INTERVIEW ________

NATIVE LANGUAGE OF RESPONDENT _________

TRANSLATOR USED

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

SUPERVISOR
NAME _____
NUMBER ______

FIELD EDITOR
NAME ______
NUMBER _______

KEYED BY
NUMBER _______

INTRODUCTION AND CONSENT:

Asalum-o-Alaikum. My name is _________. I am working with the National Institute of Population Studies. We are conducting a survey about health and other topics all over Pakistan. 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 30 to 35 minutes. All of the answers you give will be confidential and will not be shared with anyone other than the members of our survey teams. 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?

SIGNATURE OF INTERVIEWER _____________
DATE __________

RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

RECORD THE TIME
HOURS _______
MINUTES _______

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 5-34 FOR EACH PERSON.

3) RELATIONSHIP TO THE HEAD OF THE 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?

6) Did (NAME) stay here last night?

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

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

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

10) IF HOUSEHOLD SELECTED FOR MAN'S SURVEY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-49 WHO ARE MARRIED, DIVORCED/SEPARATED, OR WIDOWED.

11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

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?

17) What is the highest class (NAME) has completed? SEE CODES BELOW.

IF AGE 5-24 YEARS: CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during this school year?

19) During [this/that] school year, what class/grade [is/was] (NAME) attending? SEE CODES BELOW.

CODES FOR Q.19:

19A) What is the main reason (NAME) is not attending school?

IF AGE 0-17 YEARS: REGISTRATION WITH NADRA
20) Does (NAME) have his/her name entered onto a 'bay' form?
IF YES: Does (NAME) have a birth certificate?
IF NO: Does (NAME) have a birth certificate?

20A) Does (NAME) have NIC card?

FOR ALL USUAL MEMBERS: IN-MIGRATION

21) Was (NAME) born in this village/city?

21A) In which village/city was (NAME) born?
WRITE NAME OF PLACE.
IN THE FIRST BOX, WRITE CODE 1, 2, OR 3 AS FOLLOWS:

22) From where did (NAME) move to this village/city the last time?
WRITE NAME OF PLACE.
IN THE FIRST BOX, WRITE CODE 1, 2, OR 3 AS FOLLOWS:

23) In which year did (NAME) last move to this village/city?

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

IF AGE 5 YEARS OR OLDER: SEEING DIFFICULTY

25) Does (NAME) wear glasses or contact lenses to help them see?

26) I would like to know if (NAME) has difficulty seeing even when wearing glasses or contact lenses. Would you say that (NAME) has no difficulty seeing, some difficulty, a lot of difficulty, or cannot see at all?

27) I would like to know if (NAME) has difficulty seeing. Would you say that (NAME) has no difficulty seeing, some difficulty, a lot of difficulty, or cannot see at all?

HEARING DIFFICULTY

28) Does (NAME) wear a hearing aid?

29) I would like to know if (NAME) has difficulty hearing even when using a hearing aid. Would you say that (NAME) has no difficulty hearing, some difficulty, a lot of difficulty, or cannot hear at all?

30) I would like to know if (NAME) has difficulty hearing. Would you say that (NAME) has no difficulty hearing, some difficulty, a lot of difficulty, or cannot hear at all?

OTHER FUNCTIONAL DIFFICULTIES

31) I would like to know if (NAME) has difficulty communicating when using his/her usual language. Would you say that (NAME) has no difficulty understanding or being understood, some difficulty, a lot of difficulty, or cannot communicate at all?

32) I would like to know if (NAME) has difficulty remembering or concentrating. Would you say that (NAME) has no difficulty remembering or concentrating, some difficulty, a lot of difficulty, or cannot remember or concentrate at all?

33) I would like to know if (NAME) has difficulty walking or climbing steps. Would you say that (NAME) has no difficulty walking or climbing steps, some difficulty, a lot of difficulty, or cannot walk or climb steps at all?

34) I would like to know if (NAME) has difficulty washing all over or dressing. Would you say that (NAME) has no difficulty washing all over or dressing, some difficulty, a lot of difficulty, or cannot wash all over or at all?

OUT MIGRATION

35) Now I would like to ask you about members of this household who 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?

36) MIGRANTS: Please give me the names of the persons who are living outside of this household?
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP TO HOUSEHOLD HEAD AND SEX FOR EACH PERSON, ASK QUESTIONS 38-41A FOR EACH PERSON.

RELATION TO HOUSEHOLD HEAD
36A) What is the relationship of (NAME) to the head of the household?

37) SEX: Is (NAME) male or female?

38) MONTH AND YEAR MOVED AWAY: In what month and year did (NAME) move away?

39) AGE: How old was (NAME) when s/he moved away?
IF LESS THAN 1 YEAR, WRITE '00.' IF 95 OR MORE, RECORD '95.'

IF AGE 5 YEARS OR OLDER:

39A) EDUCATION: What was the highest class (NAME) completed when he/she moved away?

REASON FOR MIGRATION
40) What was the main reason that (NAME) moved away?

41) PLACE TRAVELLED TO: Where has (NAME) travelled to?
IF OTHER CITY OF PAKISTAN, ASK FOR NAME OF THE CITY AND CODE. IF OTHER PARTS OF PAKISTAN, ASK FOR NAME OF THE DISTRICT AND CODE. IF OUTSIDE PAKISTAN WRITE THE NAME OF THE COUNTRY AND PROVIDE THE CODE.

41A) REMITTANCE: In the past one year did you send money or receive money from (NAME)?

42) TOTAL NUMBER OF MIGRANTS _________
TICK IF CONTINUATION SHEET USED ___

SECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS

43) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR DV MODULE?

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 ARE 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 INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

IF NO ELIGIBLE WOMAN IN THE HOUSEHOLD WRITE '00' AND SKIP TO 101.

HOUSEHOLD CHARACTERISTICS

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? IF WATER IS DELIVERED AT HOME, RECORD.

105) CHECK 101 AND 102: CODE '14' OR '21'

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 household, how many households use this toilet facility?

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?

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

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

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

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

120) How many acres or kanals of agricultural land do members of this household own?

121) Does your household have:

122) Does any member of this household own:

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

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

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

126) Who sprayed the dwelling?

127) Does your household have any mosquito nets?

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

129) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

130) How many months ago did your family get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00.'

131) OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

134) Did you get the net through Continuous LLINs Distribution (CD) Program, during an antenatal care visit, or during an immunization visit?

135) Where did you get the net?

136) Did anyone sleep under this mosquito net last night?

137) Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD.

138) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139

ADDITIONAL HOUSEHOLD CHARACTERISTICS

139) We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

140) OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.

141) OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.

142) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.

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

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

146) RECORD THE TIME