JORDAN POPULATION AND FAMILY HEALTH SURVEY 1996 HOUSEHOLD QUESTIONNAIRE
1. GOVERNORATE
2. DISTRICT
3. SUBDISTRICT
4. LOCALITY
5. STRATUM NUMBER
6. CENSUS BLOCK NUMBER
7. JPFHS-II CLUSTER NUMBER
8. HOUSEHOLD NUMBER
9. URBAN/RURAL
RURAL 2
10. AMMAN/LARGE CITY/MEDIUM CITY/TOWN/COUNTRYSIDE
MEDIUM CITY 2
SMALL CITY 3
TOWN 4
COUNTRYSIDE 5
AMMAN ALMOST 1,000,000
MEDIUM CITY (ZARQA, RUSSAIFA, IRBID, SALT, MADABA) 50,000 - 500,000
SMALL CITY 20,000 - 49,999
TOWN 5,000 - 19,999
COUNTRYSIDE LESS THAN 5,000
11. NAME OF HOUSEHOLD HEAD
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER____ 9
NEXT VISIT
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER____ 9
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER____ 9
FINAL VISIT
DAY
MONTH
YEAR 1997
NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER____ 9
TOTAL NUMBER OF VISITS
TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE
FIELD EDITOR
NAME
DATE
OFFICE EDITOR
KEYED BY
Now we would like 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?
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
4. RESIDENCE: Does (NAME) usually live here?
NO 2
5. Did (NAME) stay here last night?
NO 2
6. SEX: Is (NAME) male or female?
F 2
8. Has (NAME) ever been to school?
NO 2
9. IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended? What is the highest grade (NAME) completed at that level?
10. IF AGE LESS THAN 25 YEARS: Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE
11. Is (NAME)'s natural mother alive?
NO 2
DK 8
12. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
13. Is (NAME)'s natural father alive?
NO 2
DK 8
14. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER
15. MARITAL STATUS IF AGE 15 YEARS OR OLDER: What is (NAME) current marital status?
MARRIED 2
DIVORCED 3
WIDOWED 4
SEPARATED 5
16. WOMAN: CIRCLE LINE NUMBER OF EVER MARRIED WOMEN AGE 15-49 YEARS WHO ARE USUAL RESIDENTS OR STAYED THERE ON THE NIGHT BEFORE INTERVIEW.
17. HUSBAND: CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INTERVIEW (I.E., MEN WHOSE WIVES ARE ELIGIBLE)
18. What is the main source of drinking water for members of your household?
RESIDENCE/YARD/PLOT 11 (GO TO 20)
PUBLIC TAP 12
PUBLIC WELL 22
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51 (GO TO 20)
BOTTLED WATER 61 (GO TO 20)
19. How long does it take to go there, get water, and come back?
ON PREMISIS 996
20. What kind of sewage system do you have in your house?
DUG HOLE 2
OTHER_______ 3
NO SEWAGE 4
20A. What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
OTHER___________ 96
NO 2
YES 1
NO 2
YES 1
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
22. How many rooms in your household are used for sleeping?
23. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
24. Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
25. What type of salt is usually used for cooking in your household?
(ASK TO SEE SALT PACKAGE).
PACKAGED SALT (NOT IODIZED) 2