JORDAN POPULATION AND FAMILY HEALTH SURVEY 2002 HOUSEHOLD QUESTIONNAIRE
GROUP NO:__
QUESTIONNAIRE NO:___
GOVERNORATE:____
DISTRICT:____
SUBDISTRICT:____
LOCALITY:____
STRATUM:____
URBAN/RURAL:
RURAL 2
BLOCK NO:_____
BUILDING NO:_____
HOUSING UNIT NO:_____
CLUSTER NO:_____
HOUSEHOLD NO:____
TELEPHONE NO (IF AVAILABLE):____________
HOUSEHOLD SELECTED FOR ANEMIA TESTING
NO 2
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT
2 NOT AT HOME
3 POSTPONED
4 REFUSED
5 PARTLY COMPLETED
6 INCAPACITATED
7 OTHER (SPECIFY)
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 2002
NAME
RESULT
TOTAL NUMBER OF VISITS
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 three 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. SEX: Is (NAME) a male or female?
FEMALE 2
5. Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
6A. DATE OF BIRTH: In what month and year was (NAME) born?
YEAR_______
IF DON'T KNOW MONTH: RECORD '98' FOR MONTHS
IF DON'T KNOW YEAR: RECORD '9998' FOR YEAR
7. AGE: How old is (NAME)?
(IF AGE=95+ RECORD 95)
(COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT)
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD
10. Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
11. IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name? RECORD MOTHER'S LINE NUMBER
12. Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 3
13. IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name? RECORD FATHER'S LINE NUMBER
IF AGE 6 YEARS OR OLDER:
14A. Has (NAME) ever attended school?
NO 2
14B. Can (NAME) read and write?
NO 2 (GO TO 20A)
14C. What is the highest level of school (NAME) has attended?
CODING:
02 = OLD PREPARATORY
03 = OLD SECONDARY
04 = NEW BASIC
05 = NEW SECONDARY
06 = INTERMEDIATE DIPLOMA
07 = UNIVERSITY
08 = HIGHER
98 = DON'T KNOW
14D. What is the highest grade (NAME) completed at that level?
CODING:
98 = DON'T KNOW
14E. Did (NAME) attend school at any time during the last school year?
NO 2
IF AGE 15 YEARS OR OLDER:
20A. What is (NAME)'s marital status?
MARRIED 2
DIVORCED 3
WIDOWED 4
SEPARATED 5
20B. CIRCLE LINE NUMBER OF ELIGIBLE WOMEN FOR THE INDIVIDUAL SURVEY (EVER MARRIED WOMEN AGE 15-49)
20C. CIRCLE LINE NUMBER OF NEVER MARRIED WOMEN AGE 15-49
20D. CIRCLE LINE NUMBER OF ALL CHILDREN BORN IN 1997 OR LATER, OR CHILDREN UNDER AGE 6 (IF DATE OF BIRTH IS UNKNOWN).
21. What is the main source of drinking water for members of your household?
PIPED INTO YARD 12
PUBLIC TAP 13
SPRING 21
RAINWATER 31
TANKER TRUCK 41
BOTTLED WATER 51
OTHER______ 96
21A. TYPE OF HOUSING UNIT (RECORD OBSERVATION)
DAR 2
VILLA 3
HUT/BARRACK 4
OTHER___6
23. What kind of toilet facilities does your household have?
SHARED FLUSH TOILET 12
SHARED TRADITIONAL PIT TOILET 22
OTHER___ 96
23A. Is your house connected with:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
25A. Does your household have a mobile?
IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
25B. Does your household have a private car or pick-up?
IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
26. What type of fuel does your household mainly use for cooking?
NATURAL GAS 2
KEROSENE 3
COAL, WOOD 4
OTHER_____6
27. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
VINYL 22
CERAMIC TILES 23
CEMENT 24
27A. How many rooms do you have in your house?
27B. How many rooms in your household are used for sleeping?
CHECK COLUMNS (20B), (20C), AND (20D): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN BORN IN 1997 OR LATER, OR CHILDREN UNDER AGE 6 (IF DATE OF BIRTH UNKOWN).
36. LINE NO. FROM COL. (20B) OR (20C)
39. (CHILDREN BORN IN 1997 OR LATER ONLY) DATE OF BIRTH FROM COL. (6A) AND ASK DAY
DAY____
YEAR____
42. (CHILDREN BORN IN 1997 OR LATER ONLY) MEASURED LYING DOWN OR STANDING UP.
STANDING 2
2=NOT PRESENT
3=REFUSED
6=OTHER
43A. CHECK COVER PAGE TO DETERMINE IF HOUSEHOLD IS INCLUDED IN THE SUBSAMPLE FOR ANEMIA TESTING:
NO (END)
IF YES: CHECK COLUMNS (20B), (20C) AND (20D): RECORD THE LINE NUMBER (IN COL. 45), AND AGE OF ALL WOMEN AGE 15-49 AND ALL CHILDREN BORN IN 1997 OR LATER, OR CHILDREN UNDER AGE 6 (IF DATE OF BIRTH UNKNOWN)
AGE 15-17 (GO TO 45)
AGE 18-49 (GO TO 46)
45. LINE NO. OF PARENT/RESPONSIBLE ADULT. RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE
46. READ CONSENT STATEMENT TO WOMAN/PARENT/ RESPONSIBLE ADULT. CIRCLE CODE (AND SIGN)
REFUSED (GO TO NEXT LINE)
48. CHECK (20A): IF EVER MARRIED ASK FOR CURRENT PREGNANCY, IF SINGLE, CIRCLE '3'
NO/DK 2
SINGLE 3
2=NOT PRESENT
3=REFUSED
4=OTHER
50. CHECK 47 AND 48: NUMBER OF PERSONS WITH HEMOGLOBIN LEVEL BELOW THE CUTOFF POINT
ONE OR MORE (GIVE EACH WOMEN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN MEASUREMENT AND CONTINUE WITH 51)
NONE (GIVE EACH WOMAN/PARENT/RESPONSIBLE ADULT RESULT OF HEMOGLOBIN AND END HOUSEHOLD INTERVIEW.)
51. We detected a low level of hemoglobin in (your blood/ the blood of NAME OF CHILD(REN)). This indicates that (you/NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the doctor at ____________ about (your condition/the condition of NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in (your blood/the blood of NAME OF CHILD(REN)) may be given to the doctor?
NAME(S) OF PERSON(S) WITH HEMOGLOBIN BELOW THE CUTOFF POINT:
NAME OF PARENT/RESPONSIBLE ADULT
AGREES TO REFERRAL?
NO 2