JORDAN POPULATION AND FAMILY HEALTH SURVEY 2007
The Hashemite Kingdom of Jordan
Department of Statistics
Household Survey Directorate
9 June 2007
HOUSEHOLD QUESTIONNAIRE
Survey Contents Confidential by Statistical Law
GOVERNORATE:_____
DISTRICT:_____
SUB-DISTRICT:____
LOCALITY:_____
AREA:_____
SUB- AREA:______
STRATUM:______
URBAN/RURAL:
RURAL 2
QUESTIONNAIRE NUMBER: ___
BLOCK NUMBER:_____
BUILDING NUMBER:______
HOUSING UNIT NUMBER:_____
CLUSTER NUMBER:_____
HOUSEHOLD NUMBER:____
TELEPHONE/ MOBILE NUMBER (if available) ______
HOUSEHOLD SELECTED FOR ANTHROPOMETRY AND ANEMIA TESTING
NO 2
HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE
NO2
FIRST VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT ANY TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 HOUSING UNIT VACANT OR ADDRESS NO MORE A DWELLING
7 HOUSING UNIT DESTROYED
8 HOUSING UNIT NOT FOUND
9 OTHER (SPECIFY)__________
NEXT VISIT:
DATE__
TIME__
SECOND VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT ANY TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 HOUSING UNIT VACANT OR ADDRESS NO MORE A DWELLING
7 HOUSING UNIT DESTROYED
8 HOUSING UNIT NOT FOUND
9 OTHER (SPECIFY)__________
NEXT VISIT:
DATE__
TIME__
THIRD VISIT
DATE___
INTERVIEWER'S NAME___
RESULT:
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT ANY TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 HOUSING UNIT VACANT OR ADDRESS NO MORE A DWELLING
7 HOUSING UNIT DESTROYED
8 HOUSING UNIT NOT FOUND
9 OTHER (SPECIFY)__________
FINAL VISIT
DAY__
MONTH__
YEAR 2007
INT. NUMBER__
RESULT:
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT ANY TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 HOUSING UNIT VACANT OR ADDRESS NO MORE A DWELLING
7 HOUSING UNIT DESTROYED
8 HOUSING UNIT NOT FOUND
9 OTHER (SPECIFY)__________
TOTAL NUMBER OF VISITS__
LINE NUMBER OF RESPONDENT HOUSEHOLD QUESTIONNAIRE___
FIELD EDITOR
NAME____
DATE____
OFFICE EDITOR__
KEYED BY___
Hello. My name is______________ and I am working with the Department of Statistics. We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The interview usually takes between 10 and 15 minutes to complete.
As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.
At this time, do you want to ask me anything about the survey?
May I begin the interview now?
Signature of interviewer:______________________ Date: ____________________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
1) LINE NUMBER
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 ERLATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-32 FOR EACH PERSON/
3) RELATIONSHIP TO THEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 STEPSON OR STEPDAUGHTER
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 GRAND FATHER/MOTHER
10 OTHER RELATIVE
11 ADOPTER/FOSTER CHILD
12 NOT RELATED
98 DON'T KNOW
Is (NAME) male or female?
FEMALE 2
5) Does (NAME) usually live here?
NO 2
5A) Did (NAME) stay here last night?
NO 2
In what month and year was (NAME) born?
IF DON'T KNOW MONTH, RECORD 98' FOR MONTH.
IF DON'T KNOW YEAR, RECORD 9998' FOR YEAR.
How old is (NAME)?
IF AGE IS 95 OR OLDER, RECORD 95.
COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT.
2 EGYPTIAN
3 SYRIAN
4 IRAQI
5 OTHER ARAB
6 NOT ARAB
8 DON'T KNOW
MARITAL STATUS
What is (NAME'S) marital status?
2 MARRIED
3 DIVORCED
4 WIDOWED
5 SEPARATED
9) INDIVIDUAL INTERVIEW
CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL SURVEY (EVER MARRIED WOMEN 15-49)
CHECK COVER PAGE IF THIS HOUSEHOLD IS SELECTED FOR AND ANEMIA
ANTRHOPOMETRY AND ANEMIA MEASUREMENTS
10) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.
11) CIRCLE LINE NUMBER OF ALL CHILDREN BORN IN 2002 OR LATER, OR CHILD AGE 0-5 YEARS (IF DATE OF BIRTH NOT KNOWN) .
2A) Just to make sure that I have a complete listing. Are there any other persons such as small children or infants that we have not listed?
NO
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?
NO
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
12) Is (NAME)'s natural mother alive?
NO 2 (GO TO 14)
DON'T KNOW (GO TO 14)
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?
NO 2 (GO TO 16)
DON'T KNOW (GO TO 16)
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'.
EVER ATTENDED SCHOOL
16) Has (NAME) ever attended school?
NO 2
16A) Can (NAME) read and write?
NO 2
(GO TO NEXT LINE FOR ALL ANSWERS)
17) What is the highest level of school (NAME) has attended?
02 OLD PREPARATORY
03 OLD SECONDARY
05 NEW SECONDARY
06 INTERMEDIATE DIPLOMA
07 BACHELOR
08 HIGHER EDUCATION
98 DON'T KNOW
17A) What is the highest grade (NAME) completed at that level?
98 DON'T KNOW
18) Did (NAME) attend school at any time during the (2006- 2007) school year?
NO 2
HOUSING UNIT AND HOUSEHOLD CHARACTERISTICS
100) TYPE OF HOUSING UNIT
RECORD OBSERVATION
DAR 2
VILLA 3
HUT/BARRACK 4
OTHER (SPECIFY)________ 6
101) What is the main source of drinking water for members of your household?
PIPED INTO YARD 12
RAINWATER 31
TANKER TRUCK 41
BOTTLED WATER 51
OTHER (SPECIFY)________ 96
101A) Is water normally available all day from this source?
NO 2
101B) In the last two weeks, was water unavailable for an entire day or longer?
NO 2
106) Do you do anything to the water to make it safer to drink?
NO 2 (GO TO 108)
DON'T KNOW 8 (GO TO 108)
107) What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED.
ADD BLEACH/CHLORINE B
USE WATER FILTER C
OTHER (SPECIFY)_____ X
DON'T KNOW Z
108) What kind of toilet facility do members of your household usually use?
IF FLUSH TOILET: Is your toilet connected to a public sewer system, a septic tank, a pit latrine or somewhere else?
FLUSH TO PIT LATRINE 12
FLUSH TO SOMEWHERE ELSE 13
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/ OPEN PIT 23
OTHER (SPECIFY)______ 96
109) Do you share this toilet facility with other households?
NO 2
110A) Is your house connected with electricity?
NO 2
110B) Does your household have a bed or sofa bed?
IF YES: How many beds or sofa beds does your household have?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
111) Does your household have:
A radio/ tape recorder?
NO 2
A television?
NO 2
Satellite?
NO 2
A land telephone?
NO 2
A refrigerator?
NO 2
A washing machine?
NO 2
Solar heater?
NO 2
Air conditioner?
NO 2
Fan?
NO 2
Water cooler?
NO 2
Microwave?
NO 2
Digital camera?
NO 2
111A) Does your household have a computer?
IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
111B) Does your household have a mobile?
IF YES: How many?
IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.
111A AND 11B= 0 (GO TO 112)
111D) Do you have internet access at home?
NO 2
112) What type of fuel does your household mainly use for cooking?
NATURAL GAS 2
KEROSENE 3
COAL/WOOD 4
OTHER (SPECIFY)_____ 6
116) Do you have separate room which is used as a kitchen?
NO 2
116A) Do you have an independent bathroom?
NO 2
117) MAIN MATERIAL OF THE FLOOR.
TILE 32
MARBLE/ CERAMIC TILE 33
CEMENT 34
119) MAIN MATERIAL OF THE EXTERIOR WALLS/
RECORD OBSERVATION.
MUD BRICKS WITH STONE 22
ASBSTOS/WOOD/ZINC 23
CUT STONE 32
CUT STONE AND CONCRETE 33
CONCRETE 34
OTHER (SPECIFY)_______ 96
119A) How many rooms do you have in your house?
120) How many rooms in this household are used for sleeping?
120A) Does your household own a private car or pickup?
IF YES: How many?
IF NO, RECORD '0'. IF 7 OR MORE, RECORD 7.
126A) Does any member of this household have a credit card?
NO 2
USE THIS TABLE WHEN:
1) The household is selected for the domestic violence module
AND
2) There is more than one eligible women in the household
RANDOM NUMBER TABLE FOR SELECTIONN OF WOMAN AS RESONDENT TO DOMESTIC VIOLENCE MODULE
CHECK THE HOUSEHOLD NUMBER ON THE COVER PAGE OF THE HOUSEHOLD QUESTIONNAIRE.
THIS IS THE NUMBER REOW TO SELECT.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THAT NUMBER.
THIS IS THE POSITION NUMBER OF THE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE MODULE.
IN COLUMN 9 PF THE HOUSEHOLD SCHEDULE, DRAW A BOX AROUND THE LINE NUMBER OF THE ELIGIBLE WOMAN IN THAT POSITION.
EXAMPLE:
IF THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS 6, AND THERE ARE 3 ELIGIBLE WOMEN, THE NUMBER IN THE BOX WHERE ROW 6 AND COLUMN 3 MEET IS 2, THAT MEANS THAT THE 2ND ELIGIBLE WOMAN WILL BE SELECTED FOR THE MODULE.
NOW SUPPOSE THE THREE ELIGIBLE WOMEN'S LINE NUMBERS ARE '02', '03', AND '07', THEN THE 2ND ELIGIBLE WOMAN (LINE NUMBER '03') IS SELECTED FOR THE MODULE.
HEADER FOR LEFT-HAND COLUMN: "HOUSEHOLD NUMBER" (VALUES 0-15 BELOW THIS) (ROW)
HEADER FOR TOP ROW OF TABLE: TOTAL NUMBER OF ELIGIBLE WOMEN IN THE HOUSEHOLD (COLUMN)
COLUMNS WITH 1'S, 2'S, 3'S, 4'S, 5'S, AND 6'S FILL THE CELLS OF THE TABLE.
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENTS FOR CHILDREN AGE 0-5
201) CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 208 AND FOR THE ANEMIA PROCEDURE IN 213.
202) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTROY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME'S) birth date?
204) CHECK 203: CHILD BORN IN JANUARY 2002 OR LATER?
NO 2 (GO TO 203 FOR NEXT CHILD OR, IF NO MORE, GO TO 215)
207) MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
208) RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
209) CHECK 203: IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOS MONTHS?
OLDER 2
210) LINE NUMBER OF PARENT/ OTHER ADULT RESPONSIBLE FOR THE CHILD (COLUMN 1)
RECORD '00' IF NOT LISTED
211) READ CONSENT STATEMENT TO PARENT/ OTHER ADULT RESPONSIBLE FOR CHILD.
CIRCLE CODE AND SIGN.
REFUSED 2 (IF REFUSED, GO TO 213)
212) RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET
213) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
214) GO BACK TO 203 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 215.
CONSENT STATEMENT FOR ANEMIA FOR CHILDREN
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
We request that all children born in 2002 or later participate in the anemia testing part of this survey and give a few drops of blood from a finger. The equipment used in taking blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept confidential.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you allow (NAME(S) OF CHILD(REN) to participate in the anemia test?
WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT TESTING FOR WOMEN AGE 15- 49
215) CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 216. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 219 AND FOR THE ANEMIA TEST PROCEDURE IN 227
216) LINE NUMBER (COLUMN 10)
NAME (COLUMN 2)
219) RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
18-49 YEARS 2 (GO TO 223)
221) MARITAL STATUS: CHECK COLUMN 8.
CODES 2-5 (EVER MARRIED) 2 (GO TO 223)
222) FROM COLUMN 1 RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.
223) READ ANEMIA TEST CONSENT STATEMENT. FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM PARENT/OTHER ADULT IDENTIFIED IN 222 BEFORE ASKING RESPONDENT'S CONSENT.
PARENT/ OTHER RESPONSIBLE ADULT REFUSED 2
RESPONDENT REFUSED 3
(SIGN FOR ALL ANSWERS)________
(IF REFUSED, GO TO 227)
CONSENT STATEMENT FOR ANEMIA TEST
READ CONSENT STATEMENT TO EACH RESPONDENT. CIRCLE CODE '1' IN 223 IF RESPONDENT CONSENTS TO THE ANEMIA TEST AND CODE '3' IF SHE REFUSES/
FOR NEVER-IN-UNION WOMEN AGE 15-17, ASK CONSENT FROM THE PARENT OR OTHER ADULT IDENTIFIED AS RESPONSIBLE FOR THE ADOLESCENT (SEE QUESTION 222) BEFORE ASKING THE ADOLESCENT FOR HER CONSENT. CIRCLE CODE '2' IN 223 IF THE PARENT (OTHER ADULT) REFUSES. CONDUCT THE TEST ONLY IF BOTH THE PARENT (OTHER ADULT) AND THE ADOLESCENT CONSENT.
As part of this survey, we are asking people all over the country to take an anemia test. Anemia is a serious health problem that usually results from poor nutrition, infection, or chronic disease. This survey will assist the government to develop programs to prevent and treat anemia.
For the anemia testing, we will need a few drops of blood from a finger. The equipment used in taking blood is clean and completely safe. It has never been used before and will be thrown away after each test.
The blood will be tested for anemia immediately, and the result told to you right away. The result will be kept confidential.
Do you have any questions?
You can say yes to the test, or you can say no. It is up to you to decide.
Will you (allow NAME OF ADOLESCENT to) take the anemia test?
224) PREGNANCY STATUS: CHECK COLUMN 8:
IF EVER MARRIED (CODES 2-5), ASK: Are you pregnant?
IF NEVER MARRIED (CODE 1), CIRCLE '3'
NO/ DON'T KNOW 2
NEVER MARRIED 3
225) CHECK 223 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST.
A FINAL OUTCOME FOR THE ANEMIA TEST PROCEDURE MUST BE RECORDED IN 227 FOR EACH ELIGIBLE WOMAN EVEN IF SHE WAS NOT PRESENT, REFUSED, OR COULD NOT BE TESTED FOR SOME OTHER REASON.
226) RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET
227) RECORD RESULT CODE OF HEMOGLOBIN MEASUREMENT.
NOT PRESENT 2
REFUSED 3
OTHER 6