NATIONAL FAMILY HEALTH SURVEY, INDIA 2019-20 (NFHS-5)
HOUSEHOLD QUESTIONNAIRE [STATE NAME]
IDENTIFICATION
STATE ____________________
DISTRICT _____________________
TEHSIL/TALUK ___________________
CITY/TOWN/VILLAGE _____________________
RURAL 2
PSU NUMBER ______________________
STRUCTURE NUMBER __________________
HOUSEHOLD NUMBER ______________________
NAME OF HOUSEHOLD HEAD __________________________
ADDRESS OF HOUSEHOLD HEAD __________________________
IS HOUSEHOLD SELECTED FOR THE STATE MODULE?
NO 2
IS HOUSEHOLD SELECTED FOR DRIED BLOOD SPOT (DBS) COLLECTION?
NO 2
DATE _______________________
INTERVIEWER'S NAME _______________________
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER __________________________(SPECIFY) 9
FINAL VISIT
DAY _______________
MONTH _______________
YEAR _________________
INTERVIEWER NUMBER ____________________
RESULT
COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER __________________________(SPECIFY) 9
NEXT VISIT:
DATE _________________
TIME _______________
TOTAL NUMBER OF VISITS ______________________
SUPERVISOR'S NAME _______________________
SUPERVISOR NUMBER _____________________
TOTAL PERSONS IN HOUSEHOLD ________________________
TOTAL ELIGIBLE WOMEN AGE 15-49 _________________________
TOTAL ELIGIBLE MEN AGE 15-54 _________________________
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __________________________
LANGUAGE OF QUESTIONNAIRE: HINDI 04
RESPONDENT'S MOTHER TONGUE
BENGALI 02
GUJARATI 03
HINDI 04
KANNADA 05
KASHMIRI 06
KONKANI 07
MALAYALAM 08
MANIPURI 09
MARATHI 10
NEPALI 11
ORIYA 12
PANJABI 13
SINDHI 14
TAMIL 15
TELUGU 16
URDU 17
ENGLISH 18
GARO 19
KHASI 20
OTHER ___________________________________(SPECIFY) 96
BENGALI 02
GUJARATI 03
HINDI 04
KANNADA 05
KASHMIRI 06
KONKANI 07
MALAYALAM 08
MANIPURI 09
MARATHI 10
NEPALI 11
ORIYA 12
PANJABI 13
SINDHI 14
TAMIL 15
TELUGU 16
URDU 17
ENGLISH 18
GARO 19
KHASI 20
OTHER ___________________________________(SPECIFY) 96
NO 2
INTRODUCTION AND INFORMED CONSENT
Namaste. My name is _______. I am working with (NAME OF ORGANIZATION). We are conducting a survey about health all over India. The information on family welfare and health that we collect from households and individuals 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 25-35 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. Your participation in the survey is voluntary. 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.
If you have any questions about this survey you may ask me.
ANSWER ANY QUESTIONS AND ADDRESS RESPONDENT'S CONCERNS.
If you have any further questions about this survey you may contact the persons listed on this card.
GIVE CARD WITH CONTACT INFORMATION.
Do you agree to participate in this survey?
SIGNATURE OF INTERVIEWER _________________________________
DATE __________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
RECORD TIME
MINUTES _______________________
Now we would like some information about the people who usually live in your household or who are staying with you now.
01. LINE NUMBER _____________________
02. 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 NAME, RELATIONSHIP, SEX, RESIDENCE, AND AGE FOR EACH PERSON; ASK QUESTIONS 7A(a-c) TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK QUESTIONS IN COLUMNS 8-26 FOR EACH PERSON.
03. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
BROTHER-IN-LAW OR SISTER-IN-LAW 09
NIECE/NEPHEW 10
OTHER RELATIVE 11
ADOPTED/FOSTER/STEP-CHILD 12
DOMESTIC SERVANT 13
OTHER NOT RELATED 14
DON'T KNOW 98
04. SEX: Is (NAME) male or female or transgender?
FEMALE 2
TRANSGENDER 3
05. Does (NAME) usually live here?
NO 2
06. Did (NAME) stay here last night?
NO 2
07. AGE: How old is (NAME)?
RECORD COMPLETED YEARS.
AGE LESS THAN ONE YEAR 00
AGE 95 YEARS OR MORE 95
08. MARITAL STATUS: IF AGE 13 OR OLDER
What is the current marital status of (NAME)?
MARRIED, BUT GAUNA NOT PERFORMED 2
WIDOWED 3
DIVORCED 4
SEPARATED 5
DESERTED 6
NEVER MARRIED 7
DON'T KNOW 8
09. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
09A. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15 OR OLDER
IF HOUSEHOLD IS SELECTED FOR STATE MODULE
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-54
10A. CIRCLE LINE NUMBER OF ALL MEN AGE 15 OR OLDER
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
12. BIRTH REGISTRATION: IF AGE 0-4
Does (NAME) have a birth certificate?
IF NO: Has (NAME)'s birth ever been registered with the civil authority?
REGISTRATION 2
NEITHER 3
DON'T KNOW 8
IF AGE 0-17: SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
13. Is (NAME)'s natural mother alive?
NO 2 (SKIP TO 15)
DON'T KNOW 8 (SKIP TO 15)
14. Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
IF YES: RECORD MOTHER'S LINE NUMBER
IF NO: RECORD '00'.
15. Is (NAME)'s natural father alive?
NO 2 (SKIP TO 17)
DON'T KNOW (SKIP TO 17)
16. Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?
IF YES: RECORD FATHER'S LINE NUMBER
IF NO: RECORD '00'
IF AGE IS 2-4 YEARS: PRESCHOOL
17. Is (NAME) currently attending any preschool?
NO 2 (SKIP TO 24)
DON'T KNOW 8 (SKIP TO 24)
18. IF YES: What type of preschool is (NAME) attending?
OTHER GOVERNMENT RUN PSE 2 (SKIP TO 24)
PRIVATELY RUN PSE 3 (SKIP TO 24)
OTHER 4 (SKIP TO 24)
DON'T KNOW 8 (SKIP TO 24)
19. IF AGE 5 OR OLDER: Has (NAME) ever attended school?
NO 2 (SKIP TO 24)
20. IF AGE 5 OR OLDER: What is the highest grade (NAME) has completed?
LESS THAN 1 YEAR COMPLETED 00
PRE-PRIMARY 95
DON'T KNOW 98
21. IF AGE 5-24: Did (NAME) attend school or college at any time during the 2019-2020 school year?
NO 2 (SKIP TO 23)
22. IF AGE 5-24: During (this/that) school or college year, what grade/year (is/was) (NAME) attending?
23. IF AGE 5-24: What is the main reason (NAME) is not attending school?
24. Does (NAME) have an Aadhaar card or Aadhaar number?
NO 2
25. IF AGE 15 OR OLDER: Does (NAME) currently smoke or use tobacco in any form?
NO 2
DON'T KNOW 8
26. IF AGE 15 OR OLDER: Does (NAME) currently drink alcohol?
NO 2
DON'T KNOW 8
TICK HERE IF CONTINUATION QUESTIONNAIRE USED __
7A. Just to make sure that I have a complete household listing:
a) Are there any other persons such as small children or infants that we have not listed?
NO _
b) 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
c) Are there any other guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
(A) CODES FOR Q.3
RELATIONSHIP TO HEAD OF HOUSEHOLD:
WIFE OR HUSBAND = 02
SON OR DAUGHTER = 03
SON-IN-LAW OR DAUGHTER-IN-LAW = 04
GRANDCHILD = 05
PARENT = 06
PARENT-IN-LAW = 07
BROTHER OR SISTER = 08
BROTHER-IN-LAW OR SISTER-IN-LAW = 09
NIECE/NEPHEW = 10
OTHER RELATIVE = 11
ADOPTED/FOSTER/STEP-CHILD = 12
DOMESTIC SERVANT = 13
OTHER NOT RELATED = 14
DON'T KNOW = 98
AGE 95 YEARS OR MORE = 95
(C) CODES FOR Q.8
MARITAL STATUS:
MARRIED, BUT GAUNA NOT PERFORMED = 2
WIDOWED = 3
DIVORCED = 4
SEPARATED = 5
DESERTED = 6
NEVER MARRIED = 7
DON'T KNOW = 8
(D) CODES FOR Q.12
BIRTH REGISTRATION:
R = REGISTRATION = 2
N = NEITHER = 3
DK = DON'T KNOW = 8
OTHER GOVERNMENT RUN PSE = 2
PRIVATELY RUN PSE = 3
OTHER = 4
DON'T KNOW = 8
(F) CODES FOR Q.20 AND Q.22
EDUCATION GRADE:
PRE-PRIMARY = 95
DON'T KNOW = 98
(G) CODES FOR Q.23
REASON FOR NOT ATTENDING SCHOOL:
TRANSPORT NOT AVAILABLE = 02
FURTHER EDUCATION NOT CONSIDERED NECESSARY = 03
REQUIRED FOR HOUSEHOLD WORK = 04
REQUIRED FOR WORK ON FARM/FAMILY BUSINESS = 05
REQUIRED FOR OUTSIDE WORK FOR PAYMENT IN CASH OR KIND = 06
COSTS TOO MUCH = 07
NO PROPER SCHOOL FACILITIES FOR GIRLS = 08
DUE TO DISASTER/NATURAL CALAMITY = 09
NOT SAFE TO SEND GIRLS = 10
NO FEMALE TEACHER = 11
REQUIRED FOR CARE OF SIBLINGS = 12
NOT INTERESTED IN STUDIES = 13
REPEATED FAILURES = 14
GOT MARRIED = 15
DID NOT GET ADMISSION = 16
OTHER = 96
DON'T KNOW = 98
27. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5
28. Does any usual resident of your household including you suffer from tuberculosis?
NO 2 (SKIP TO 31)
29. Who suffers from tuberculosis?
Anyone else?
IF NO MORE TB CASES, RECORD '95'.
30. Has (NAME) received medical treatment for the tuberculosis?
IF YES, ASK: Where did (NAME) go?
YES, PUBLIC ONLY 1
YES, PRIVATE ONLY 2
YES, BOTH 3
NO 4
LINE NO. ____
YES, PUBLIC ONLY 1
YES, PRIVATE ONLY 2
YES, BOTH 3
NO 4
LINE NO. ____
YES, PUBLIC ONLY 1
YES, PRIVATE ONLY 2
YES, BOTH 3
NO 4
LINE NO. ____
YES, PUBLIC ONLY 1
YES, PRIVATE ONLY 2
YES, BOTH 3
NO 4
31. Does any usual resident of your household including you have any disability?
NO 2 (SKIP TO 34)
32. Please tell me the names of those persons.
RECORD NAME AND LINE NUMBER OF EACH PERSON MENTIONED.
IF NO MORE PERSONS WITH ANY DISABIILTY, RECORD '95'.
2. NAME _______________ LINE NO. _____
3. NAME _______________ LINE NO. _____
4. NAME _______________ LINE NO. _____
33. FOR EACH PERSON WITH A DISABILTY, ASK:
What type of disability does (NAME) have?
Any other?
HEARING A
SPEECH B
VISUAL C
MENTAL D
LOCOMOTOR E
OTHER X
LINE NUMBER _________
HEARING A
SPEECH B
VISUAL C
MENTAL D
LOCOMOTOR E
OTHER X
LINE NUMBER _________
HEARING A
SPEECH B
VISUAL C
MENTAL D
LOCOMOTOR E
OTHER X
LINE NUMBER _________
HEARING A
SPEECH B
VISUAL C
MENTAL D
LOCOMOTOR E
OTHER X
34. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 37B)
PIPED TO NEIGHBOR 13
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLE 21
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
COMMUNITY RO PLANT 92
OTHER 96 (SPECIFY)
35. Where is the water source located?
IN OWN YARD/PLOT 2 (SKIP TO 37B)
ELSEWHERE 3
36. How long does it take to go there, get water, and come back in one trip?
DELIVERED TO DWELLING 000 (SKIP TO 37B)
ON THE PREMISES 996 (SKIP TO 37B)
DON'T KNOW 998
37. Who usually goes to this source to fetch the water for your household?
ADULT MAN 2
FEMALE CHILD UNDER AGE 15 YEARS 3
MALE CHILD UNDER AGE 15 YEARS 4
OTHER 6 (SPECIFY) ___
37A. CHECK 34: CODE '13' OR '14' OR '21' CIRCLED?
NONE CIRCLED (SKIP TO 38)
37B. 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
38. Does this household do anything to the water to make it safer to drink?
NO 2 (SKIP TO 40)
DON'T KNOW 8 (SKIP TO 40)
39. What does this household usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED.
USE ALUM B
ADD BLEACH/CHLORINE TABLETS C
STRAIN THROUGH A CLOTH D
USE WATER FILTER (CERMAIC/SAND/COMPOSITE/ETC.) E
USE ELECTRONIC PURIFIER F
USE SOLAR DISINFECTION G
LET IT STAND AND SETTLE H
OTHER X (SPECIFY) __
DON'T KNOW Z
40. What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
SINGLE PIT LATRINE WITH SLAB 22
SINGLE PIT LATRINE WITHOUT SLAB/OPEN PIT 23
DRY TOILET 41
NO FACILITY/USES OPEN SPACE OR FIELD 51 (SKIP TO 44)
OTHER 96 (SPECIFY) __
41. Where is the toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE 3
42. Do you share this toilet facility with other households?
NO 2 (SKIP TO 46)
43. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95 (SKIP TO 46)
DON'T KNOW 98 (SKIP TO 46)
44. Do members of your household have access to a toilet facility?
NO 2 (SKIP TO 46)
45. What kind of toilet facility do members of your household have access to?
COMMUNITY TOILET 2
SHARED TOILET WITH OTHER HOUSEHOLD 3
46. What type of drainage facility does your household have?
OPEN DRAINAGE 2
DRAIN TO SOAK PIT 3
NO DRAINAGE 4
47. What is the religion of the head of the household?
MUSLIM 02
CHRISTIAN 03
SIKH 04
BUDDHISTINE/NEO-BUDDHIST 05
JAIN 06
JEWISH 07
PARSI/ZOROASTRIAN 08
NO RELIGION 09
OTHER 96 (SPECIFY) __
48. What is the caste or tribe of the head of the household?
TRIBE 992 (SPECIFY) __
NO CASTE/TRIBE 993 (SKIP TO 50)
DON'T KNOW 998
49. Is this a scheduled caste, a schedule tribe, other backward class, or none of them?
SCHEDULED TRIBE 2
OTHER BACKWARD CLASS 3
NONE OF THEM 4
DON'T KNOW 8
a) Electricity?
b) A mattress?
c) A pressure cooker?
d) A chair?
e) A cot or bed?
f) A table?
g) A electric fan?
h) A radio or transistor?
i) A black and white television?
j) A colour television?
k) A sewing machine?
l) A mobile telephone?
m) A landline telephone?
n) Internet?
o) A computer?
p) A refrigerator?
q) An air conditioner?
r) A washing machine?
s) A watch or clock?
t) A bicycle?
u) A motorcycle or scooter?
v) An animal-drawn cart?
w) A car?
x) A water pump?
y) A thresher?
z) A tractor?
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
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
51. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02 (SKIP TO 53)
BIOGAS 03 (SKIP TO 53)
KEROSENE 04
COAL/LIGNITE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP WASTE 09
DUNG CAKES 10
NO FOOD COOKED IN HOUSEHOLD 95 (SKIP TO 57)
OTHER 96 (SPECIFY) __
52. In this household, is food cooked on a stove, a chullah, or an open fire?
CHULLAH 2
OPEN FIRE 3
OTHER 6 (SPECIFY) __
53. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (SKIP TO 56)
OUTDOORS 3 (SKIP TO 56)
OTHER 6 (SPECIFY) __
54. Do you have a separate room which is used as a kitchen?
NO 2
55. Does the room used for cooking have any ventilation?
NO 2
56. How does this household dispose of the kitchen waste?
RECORD ALL MENTIONED.
OPEN DRAIN B
CLOSED DRAIN C
REUSE FOR GARDEN OR FARMING D
REUSE FOR OTHER DOMESTIC PURPOSES E
MANUAL COLLECTION F
OTHER X (SPECIFY) __
57. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
SAND 12
DUNG 13
PALM/BAMBOO 22
BRICK 23
STONE 24
VINYL OR ASPHALT 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
POLISHED STONE/MARBLE/GRANITE 36
58. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
THATCH/PALM LEAF/REED/GRASS 12
MUD 13
SOD/MUD AND GRASS MIXTURE 14
PLASTIC/POLYTHENE SHEETING 15
PALM/BAMBOO 22
RAW WOOD PLANKS/TIMBER 23
UNBURNT BRICK 24
LOOSELY PACKED STONE 25
WOOD 32
CALAMINE/CEMENT FIBER 33
ASBESTOS SHEETS 34
RCC/RBC/CEMENT/CONCRETE 35
ROOFING SHINGLES 36
TILES 37
SLATE 38
BURNT BRICK 39
59. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.
CANE/PALM/TRUNKS/BAMBOO 12
MUD 13
GRASS/REEDS/THATCH 14
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
UNBURNT BRICK 25
RAW WOOD/REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BURNT BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
GI/METAL/ASBESTOS SHEETS 36
60. How many rooms in this household are used for sleeping?
61. Does any member of this household own this house or any other house?
NO 2 (SKIP TO 63)
FEMALE MEMBER 2
BOTH 3
DON'T KNOW 8
63. Does any member of this household own any agricultural land?
NO 2 (SKIP TO 67)
64. Who owns this agricultural land?
FEMALE MEMBER 2
BOTH 3
DON'T KNOW 8
65. How much agricultural land do members of this household own?
_____________________________________
(IF NOT IN ACRES, THEN CONVERT INTO ACRES)
66. Out of this land, how much is irrigated?
_____________________________________
(IF NOT IN ACRES, THEN CONVERT INTO ACRES)
NONE 9995
DON'T KNOW 9998
67. Does your household own any of the following animals:
a) Cows, bulls, buffaloes, or yaks?
b) Camels?
c) Horses, donkeys, or mules?
d) Goats or sheep?
e) Pigs?
f) Chickens or ducks?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
ALL 'NO' (SKIP TO 70)
69. Does this household share a sleeping room with (this/these) animal(s)?
NO 2
70. Does any usual member of this household have a bank account or a post office account?
NO 2
DON'T KNOW 8
71. Is any usual member of this household, covered by a health scheme or health insurance?
NO 2 (SKIP TO 73)
DON'T KNOW 8 (SKIP TO 73)
72. What type of health scheme or health insurance?
Any other type?
RECORD ALL MENTIONED.
CENTRAL GOVERNMENT HEALTH SCHEME (CGHS) B
STATE HEALTH INSURANCE SCHEME C
RASHTRIYA SWASTHYA BIMA YOJANA (RSBY) D
COMMUNITY HEALTH INSURANCE PROGRAMME E
OTHER HEALTH INSURANCE THROUGH EMPLOYER F
MEDICAL REIMBURSEMENT FROM EMPLOYER G
OTHER PRIVATELY PURCHASED COMMERICAL HEALTH INSURANCE H
OTHER X (SPECIFY) __
73. When members of your household get sick, where do they generally go for treatment?
GOVT. DISPENSARY 12 (SKIP TO 75)
UHC/UHP/UFWC 13 (SKIP TO 75)
CHC/RURAL HOSPITAL/BLOCK PHC 14 (SKIP TO 75)
PHC/ADDITIONAL PHC 15 (SKIP TO 75)
SUB-CENTRE 16 (SKIP TO 75)
YOGA AND ANTUROPATHY 18 (SKIP TO 75)
UNANI 19 (SKIP TO 75)
SIDDHA 20 (SKIP TO 75)
HOMEOPATHY 21 (SKIP TO 75)
SOWA RIGPA (TTM) 22 (SKIP TO 75)
OTHER 23 (SPECIFY) __ (SKIP TO 75)
ANGANWADI.ICDS CENTRE 24
ASHA 25
GOVT. MOBILE CLINIC 26
OTHER PUBLIC HEALTH SECTOR 27
PVT. DOCTOR/CLINIC 42
PVT. PARAMEDIC 43
AYUSH
AYURVEDA 44
YOGA AND NATUROPATHY 45
UNANI 46
SIDDHA 47
HOMEOPATHY 48
SOWA RIGPA (TTM) 49
OTHER 50 (SPECIFY) __
PHARMACY/DRUGSTORE 52
DAI (TBA) 53
OTHER PRIVATE HEALTH SECTOR 54
HOME TREATMENT 62
74. Why don't members of your household generally go to a government facility when they are sick?
Any other reason?
RECORD ALL MENTIONED.
FACILITY TIMING NOT CONVENIENT B
HEALTH PERSONNEL OFTEN ABSENT C
WAITING TIME TOO LONG D
POOR QUALITY OF CARE E
OTHER X (SPECIFY) __
75. Does your household have a BPL card?
NO 2
DON'T KNOW 8
76. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (SKIP TO 83)
77. How many mosquito nets does your household have?
IF 7 OR MORE NET, RECORD '7'.
78. OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
LONG-LASTING INSECTICIDE TREATED NET (LLIN)
DURANET 12
INTERCEPTOR 13
LIFENET 14
MAGNET 15
NETPROTECT 16
OLYSET 17
PERMANET 18
ROYAL SENTRY 19
YORKOOL 20
OTHER/DK BRAND 26
DON'T KNOW TYPE 98
79. From where did you get the mosquito net?
GOVERNMENT 2
SUPPLIED BY NGO/TRUST 3
OTHER 6 (SPECIFY) __
DON'T KNOW 8
80. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 82)
NOT SURE 8 (SKIP TO 82)
81. Who slept under this mosquito net last night?
RECORD PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. __
NAME __
LINE NO. __
NAME __
LINE NO. __
NAME __
LINE NO. __
82. GO BACK TO 78 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 83.
83. We would now 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?
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (SKIP TO 86)
NOT OBSERVED, NO PERMISSION TO SEE 3 (SKIP TO 86)
NOT OBSERVED, OTHER REASON 4 (SKIP TO 86)
84. OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.
WATER IS NOT AVAILABLE 2
85. OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.
RECORD ALL MENTIONED.
ASH, MUD, SAND B
NONE C
86. I would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED 6 (SPECIFY REASON) __
87. Did any usual member of this household die since January 2016?
NO 2 (SKIP TO 96)
89. Please tell me the name(s) of the (person/people) who died.
NAME
90. Was (NAME) male or female?
FEMALE 2
91. Was (NAME)'s death registered with the civil authority?
NO 2
92. How old was (NAME) when (he/she) died?
RECORD IN DAYS OR MONTHS OR YEARS.
MONTHS 2 __
YEARS 3 __
93. In what month and year did (NAME) die?
YEAR __
94. IF FEMALE AND DIED WHEN 12 YEARS OR OLDER: Did (NAME) die during pregnancy, during childbirth or within two months after the end of pregnancy or childbirth?
NO 2
95. Was the death due to an accident, violence, poisoning, drowning, disaster, homicide, or suicide?
NO 2
MINUTES __
INTERVIEWER'S OBSERVATIONS __
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ON SPECIFIC QUESTIONS: __
ANY OTHER COMMENTS: __
SUPERVISOR'S OBSERVATIONS __
NAME OF SUPERVISOR: __
DATE: __