March 8, 2012
Department of Statistics
Household Survey Directorate

Survey Contents Confidential by Statistical Law

IDENTIFICATION:

GOVERNORATE: _____
DISTRICT: _____
SUB-DISTRICT: _____
LOCALITY: _____
AREA: _____
SUB-AREA: _____
STRATUM: _____
URBAN/RURAL

QUESTIONNAIRE NUMBER: _____
BLOCK NUMBER: _____
BUILDING NUMBER: _____
HOUSING UNIT NUMBER: _____
CLUSTER NUMBER: _____
HOUSEHOLD NUMBER: _____
TELEPHONE/MOBILE NUMBER (if available) ___________

HOUSEHOLD SELECTED FOR ANTHROPOMETRY, ANEMIA TESTING, CHILD DISCIPLINE AND DOMESTIC VIOLENCE MODULE?

INTERVIEWER VISITS: (REPEAT FOR SECOND AND THIRD VISITS)
:
DATE _____
INTERVIEWER'S NAME _____
RESULT* ______

*RESULT CODES

NEXT VISIT
DATE _____
TIME _____

FINAL VISIT
DAY _____
MONTH ____
YEAR ____
INTERVIEW NUMBER ____
RESULT _____

TOTAL NUMBER OF VISITS ___

TOTAL PERSONS IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
LINE NO. OF RESPONDENT HOUSEHOLD QUESTIONNAIRE ____

SUPERVISOR
NAME _____
DATE ____

FIELD EDITOR
NAME _____
DATE _____

OFFICE EDITOR _____

KEYED BY _____

INTRODUCTION AND CONSENT

Hello. My name is _______________. I am working with the Department of Statistics. We are conducting a survey about health all over Jordan. 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 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. 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?
May I begin the interview now?

SIGNATURE OF INTERVIEWER: __________
DATE: __________

HOUSEHOLD SCHEDULE

1. LINE NUMBER _____

2. USUAL RESIDENT AND VISITORS: Please give me the names of the persons who usually live in your 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 5-20 FOR EACH PERSON.

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

4. SEX: Is (NAME) male or female?

5. RESIDENCE: Does (NAME) usually live here?

5A. Did (NAME) stay here last night?

6. DATE OF BIRTH: 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.

6A. AGE: How old is (NAME)?
IF AGE =95+, RECORD 95.
COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT.

7. NATIONALITY: What is (NAME'S) nationality?

MARITAL STATUS. IF AGE 15 OR OLDER:

8. What is (NAME'S) current marital status?

ELIGIBILITY:
9. INDIVIDUAL INTERVIEW: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL SURVEY (EVER-MARRIED WOMEN AGE 15-49).

ELIGIBILITY:
CHECK COVER PAGE IF THIS HOUSEHOLD IS SELECTED FOR ANTHROPOMETRY AND ANEMIA

ANTHROPOMETRY AND ANEMIA MEASUREMENTS:
10. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49.

11. CIRCLE LINE NUMBER OF ALL CHILDREN BORN IN 2007 OR LATER, OR CHILDREN AGE 0-5 YEARS (IF DATE OF BIRTH NOT KNOWN)

TICK HERE IF CONTINUATION SHEET USED _____

2A. Just to make sure I have a complete listing: Are there any other persons such as small children or infants that we have not listed?

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?

2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS. IF AGE 0-17 YEARS:

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'.

EVER ATTENDED SCHOOL. IF AGE 5 YEARS OR OLDER:

16. Has (NAME) ever attended school?

16A. Can (NAME) read and write?

17. What is the highest level of school (NAME) has attended? SEE CODES.

17A. What is the highest grade (NAME) completed at the level? SEE CODES.

18. IF AGE 5-24 YEARS: Did (NAME) attend school at any time during the current (2012-13) school year?

BIRTH REGISTRATION. IF AGE 0-4 YEARS:

20. Does (NAME) have a birth certificate? IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority

HOUSING UNIT AND HOUSEHOLD CHARACTERISTICS

100. TYPE OF HOUSING UNIT. RECORD OBSERVATION

101. How often does anyone smoke cigarette/nargila inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

102. What is your main source of drinking water for members of your household?

105. Do you do anything to the water to make it safer to drink?

106. What do you usually do to make the water safer to drink?
Anything else?
RECORD ALL MENTIONED.

107. 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?

108. Do you share this toilet facility with other households?

109. How many households use this toilet facility?

109A. Is your house connected with electricity?

109B. 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.

110. Does your household have:

A radio/tape recorder?
A television?
Satellite?
A land telephone?
A refrigerator?
A freezer?
A washing machine?
A dish washer?
Solar heater?
Air conditioner?
Fan?
Water cooler?
Microwave?
Digital camera?

110A. Does your household have a computer?
IF YES: How many? IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

110B. Does your household have a mobile?
IF YES: How many? IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

110C. CHECK 110A and 110B:

110D. Do you have internet access at home?

111. What type of fuel does your household mainly use for cooking?

113. Do you have a separate room which is used as a kitchen?

113A. Do you have an independent bathroom?

114. MAIN MATERIAL OF THE FLOOR.

115. MAIN MATERIAL OF THE ROOF
RECORD OBSERVATION.

116. MAIN MATERIAL OF THE EXTERIOR WALLS
RECORD OBSERVATION.

116A. How many rooms do you have in your house?

117. How many rooms in this household are used for sleeping?

118. Does your household own a private car or pickup?
IF YES: How many? IF NONE, RECORD '0'. IF 7 OR MORE, RECORD 7.

123A. Does any member of this household have a credit card?

CHILD DISCIPLINE

141. CHECK THE COVER PAGE:

142. CHECK HOUSEHOLD SCHEDULE, COLUMN 6A:

LIST EACH OF THE CHILDREN AGED 2-14 YEARS BELOW IN THE ORDER THEY APPEAR IN THE HOUSEHOLD SCHEDULE. DO NOT INCLUDE OTHER HOUSEHOLD MEMBERS OUTSIDE OF THE AGE RANGE 2-14 YEARS.

143. RANK NUMBER:

144. LINE NUMBER FROM COLUMN 1 IN HOUSEHOLD SCHEDULE

145. NAME OF THE CHILD FROM COLUMN 2 IN THE HOUSEHOLD SCHEDULE

146. CHILD'S AGE FROM COLUMN 6A

147. WRITE PARENT'S OR CARETAKER'S LINE NUMBER/NAME FROM COLUMN 13, 15 OR 1 IN THE HOUSEHOLD SCHEDULE

148. CHECK COLUMN 146:

RANDOM NUMBER TABLE FOR SELECTION OF CHILDREN FOR THE CHILD DISCIPLINE QUESTIONS

-LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE.
-LOOK AT COLUMN 146 AND RECORD THE TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 2-14 __________. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE.
-IF THERE ARE MORE THAN 8 ELIGIBLE CHILDREN IN THE HOUSEHOLD, CIRCLE '8' IN THE ROW AT THE TOP OF THE TABLE.
-FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE RANK NUMBER OF THE ELIGIBLE CHILD WHOSE PARENT OR CARETAKER WILL BE ASKED THE QUESTIONS ON CHILD DISCIPLINE.
-THEN, GO TO COLUMN 144 AND PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED CHILD AND RECORD CHILD'S HOUSEHOLD LINE NUMBER AND NAME IN Q. 149 AND RECORD CHILD'S PARENT OR OTHER MOST KNOWLEDGEABLE ADULT'S NAME AND LINE NUMBER IN Q. 150.

FOR EXAMPLE, IF THE HOUSEHOLD QUESTIONNAIRE NUMBER IS '0716'. GO TO ROW 6 AND CIRCLE THE ROW NUMBER ('6').
- IF THERE ARE THREE ELIGIBLE CHILDREN IN THE HOUSEHOLD, GO TO COLUMN 3 AND CIRCLE THE COLUMN NUMBER ('3').
-DRAW LINES FROM ROW 6 AND COLUMN 3 AND FIND THE BOX WHERE THE TWO MEET, AND CIRCLE THE NUMBER IN IT ('2'). THIS MEANS YOU HAVE TO SELECT THE SECOND ELIGIBLE CHILD.
-SUPPOSE THE HOUSEHOLD LINE NUMBERS OF THE THREE ELIGIBLE CHILDREN ARE '02', '03'. AND '07'; THEN THE ELIGIBLE CHILD FOR THE QUESTIONS ON CHILD DISCIPLINE IS THE SECOND ELIGIBLE CHILD, I.E., THE CHILD WITH HOUSEHOLD LINE NUMBER '03'.
-PUT A * NEXT TO THIS CHILD'S LINE NUMBER IN COLUMN 144 AND ALSO ENTER THE TWO DIGIT LINE NUMBER AND CHILD'S NAME IN Q. 149.
-THEN, RECORD THE LINE NUMBER AND A NAME OF CHILD'S PARENT OR OTHER MOST KNOWLEDGEABLE ADULT IN Q. 150.

(SEE PDF FOR TABLE)

149. LINE NUMBER AND NAME OF THE SELECTED CHILD AGE 2-14 YEARS FROM COLUMNS 144 AND 145

150. LINE NUMBER AND NAME OF CHILD'S MOTHER, FATHER OR OTHER PRIMARY CARETAKER FROM COLUMN 147

THE FOLLOWING QUESTIONS 150-161 ON CHILD DISCIPLINE ARE TO BE ADMINISTERED ONLY TO THE MOST KNOWLEDGEABLE ADULT (MOTHER, FATHER, OTHER PRIMARY CARETAKER OR A GUARDIAN OF A CHILD).

All adults use certain ways to teach or to address a behavior problem. I will read various methods that are used. I want you to tell me if you or anyone else in the household has used this method with (NAME) in the past month.

151. Took away privileges, forbade something (NAME) liked or did not allow him/her to leave the house (in the past month)?

152. Explained why some behavior was wrong (in the past month)?

153. Shook him/her (in the past month)?

154. Shouted, yelled or screamed at (NAME) in the past month?

155. Gave him/her something else to do (in the past month)?

156. Spanked, hit or slapped him/her on the bottom with bare hand (in the past month)?

157. Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other (in the past month)?

158. Called him/her dumb, lazy, or a similar name (in the past month)?

159. Hit or slapped him/her on the face, head or ears (in the past month)?

160. Hit or slapped him/her on the hand, arm or leg (in the past month)?

161. Beat her/him up with an implement (hit over and over as hard as one could) (in the past month)?

162. Do you believe that in order to bring up (raise, educate) (NAME) properly, you need to physically punish him/her?

LIST OF EVER-MARRIED WOMEN AGE 15-49

163. CHECK HOUSEHOLD SCHEDULE, COLUMN 6A:

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

-LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD CIRCLE.
-LOOK AT COLUMN 9 AND RECORD THE TOTAL NUMBER OF ELIGIBLE WOMEN ______. THIS IS THE COLUMN NUMBER YOU SHOULD CIRCLE.
-IF THERE ARE MORE THAN 8 ELIGIBLE CHILDREN IN THE HOUSEHOLD, CIRCLE '8' IN THE ROW AT THE TOP OF THE TABLE.
-FIND THE BOX WHERE THE CIRCLED ROW AND THE CIRCLED COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE RANK NUMBER OF THE ELIGIBLE WOMAN WHO WILL BE ASKED THE DOMESTIC VIOLENCE MODULE.
-IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE, PUT A * NEXT TO THE HOUSEHOLD LINE NUMBER OF THE SELECTED WOMAN IN THAT POSITION.

EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBER 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, 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 DOMESTIC VIOLENCE MODULE (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE (Q. 164).

(SEE PDF FOR TABLE)

164.

WEIGHT, HEIGHT AND HEMOGLOBIN MEASUREMENT FOR CHILDREN AGE 0-5

201. CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202. LINE FROM COLUMN 11.
NAME FROM COLUMN 2.

203. IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

204. CHECK 203:
CHILD BORN IN JANUARY 2007 OR LATER?

205. WEIGHT IN KILOGRAMS

206. HEIGHT IN CENTIMETERS

207. MEASURED LYING DOWN OR STANDING UP?

208. CHECK 203:
IS CHILD AGE 0-5 MONTHS, I.E., WAS CHILD BORN IN MONTH OF INTERVIEW OR FIVE PREVIOUS MONTHS?

209. LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR THE CHILD (FROM COLUMN 1 OF HOUSEHOLD SCHEDULE). RECORD '00' IF NOT LISTED.

210. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 209 AS RESPONSIBLE FOR CHILD.

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 ask that all children born in 2007 or later take part in anemia testing in this survey and give a few drops of blood from a finger or heel. The equipment used to take the 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 will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
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 CHILD) to participate in the anemia test?

211. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

212. RECORD HEMOGLOBIN LEVEL HERE AND IN THE ANEMIA PAMPHLET

213. GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

WEIGHT, HEIGHT, AND HEMOGLOBIN MEASUREMENT TESTING FOR WOMEN AGE 15-49

214. CHECK COLUMN 10. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215. LINE NUMBER (COLUMN 10)
NAME (COLUMN 2)

216. WEIGHT IN KILOGRAMS

217. HEIGHT IN CENTIMETERS

218. AGE: CHECK COLUMN 6A.

219. MARITAL STATUS: CHECK COLUMN 8.

220. RECORD LINE NUMBER OF PARENT/OTHER ADULT RESPONSIBLE FOR ADOLESCENT. RECORD '00' IF NOT LISTED.

221. ASK CONSENT FOR ANEMIA TEST FROM PARENT/OTHER ADULT IDENTIFIED IN 220 AS RESPONSIBLE FOR NEVER IN UNION WOMEN AGE 15-17.

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 to take the 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 will be told to you and (NAME OF ADOLESCENT) right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
Do you have any questions?
You can say yes to the test for (NAME OF ADOLESCENT), or you can say no. It is up to you to decide.
Will you allow (NAME OF ADOLESCENT) to take the anemia test?

222. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

223. ASK CONSENT FOR ANEMIA TEST FROM RESPONDENT.

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 to take to 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 will be told to you right away. The result will be kept strictly confidential and will not be shared with anyone other than members of our survey team.
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 take the anemia test?

224. CIRCLE THE APPROPRIATE CODE AND SIGN YOUR NAME.

225. PREGNANCY STATUS: FIRST CHECK COLUMN 8:
IF EVER MARRIED (CODES 2-5), ASK: Are you pregnant?
IF NEVER MARRIED (CODE 1), CIRCLE '3'

239. CHECK 224 AND PREPARE EQUIPMENT AND SUPPLIES FOR THE TEST FOR WHICH CONSENT HAS BEEN OBTAINED AND PROCEED WITH THE TEST.

240. RECORD HEMOGLOBIN LEVEL HERE AND IN ANEMIA PAMPHLET.

242. GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END INTERVIEW.