NAME AND CODE OF DISTRICT
NAME AND CODE OF VILLAGE/MUNICIPALITY
WARD NUMBER
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
HOUSEHOLD SELECTED FOR MAN'S SURVEY?
NO 2
FIRST VISIT
DATE
INTERVIEWER NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT 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
SECOND VISIT
DATE
INTERVIEWER NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT 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
THIRD VISIT
DATE
INTERVIEWER NAME
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT 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
INT. NUMBER
RESULT
NO HOUSEHOLD MEMBER AT HOME OR COMPETENT RESPONDENT IN HOUSEHOLDAT 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
TOTAL NUMBER OF VISITS
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW
NEPALI 02
MAITHALI 03
BHOJPURI 04
OTHER 05
NATIVE LANGUAGE OF RESPONDENT
NEPALI 02
MAITHALI 03
BHOJPURI 04
OTHER 05
TRANSLATOR USED
NO 2
NUMBER ___
OFFICE EDITOR
KEYED BY
Hello. My name is _______________________________________. I am working with Ministry of Health. We are conducting a survey about health and other topics all over Nepal. 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 20 to 30 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. No part of this interview is being recorded in tape or video. 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.
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER ___________________________DATE _________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES ___
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.
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.
2A. Just to make sure that I have a complete listing: are there any other people 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
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE/HUSBAND 2
SON/DAUGHTER 3
SON/DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
SIBLING 8
BROTHER/SISTER-IN-LAW 9
NIECE/NEPHEW 10
CO-WIFE 11
OTHER RELATIVE 12
ADOPTED/FOSTER/STEPCHILD 13
NOT RELATED 14
DON'T KNOW 96
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
7. AGE: How old is (NAME)? IF 95 OR MORE, RECORD '95'
IF AGE 15 OR OLDER
8. MARITAL STATUS: What is (NAME)'s current marital status?
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED 4
9. ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
IF HOUSEHOLD SELECTED FOR MAN'S SURVEY
10. CIRCLE LINE NUMBER OF ALL MEN AGE 15-49
IF HOUSEHOLD SELECTED FOR MAN'S SURVEY
10A. CIRCLE LINE NUMBER OF ALL WOMEN AND MEN 15 YEARS AND ABOVE
IF HOUSEHOLD SELECTED FOR MAN'S SURVEY
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
12. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Is (NAME)'s natural mother alive?
NO 2 (GO TO 14)
DK 8 (GO TO 14)
13. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: Does (NAME)'s natural mother usually live in the household or was she a guest last night?
IF YES: What is her name? RECORD MOTHER'S LINE NUMBER, IF NO. RECORD '00'
14. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS; Is (NAME)'s natural father alive?
NO 2 (GO TO 16)
DK (GO TO 16)
15. SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS: 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'.
16. EVER ATTENDED SCHOOL: Has (NAME) ever attended school?
NO 2
16A. Has (NAME) ever participated in a literacy program or any other program that involves learning to read and write (not including primary schools)?
NO (NEXT LINE)
17B. What is the highest grade (NAME) has completed? SEE CODES BELOW
GRADE 1 -- GRADE 10 0-10
GRADE 11 AND ABOVE 11
SCHOOL BASED PRE-PRIMARY CENTERS 94
INFORMAL PRESCHOOL 95
DON'T KNOW 98
18. CURRENT/RECENT SCHOOL ATTENDANCE: Did (NAME) attend school at any time during the 2072-2073 school year?
NO 2 (NEXT LINE)
19B. During [this/that] school year, what grade [is/was] (NAME) attending? SEE CODES BELOW
GRADE 1 -- GRADE 10 0-10
GRADE 11 AND ABOVE 11
SCHOOL BASED PRE-PRIMARY CENTERS 94
INFORMAL PRESCHOOL 95
DON'T KNOW 98
20. BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the VDC/municipality?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
21. Now I would like to ask you about members of this household who lived here in the past 10 years but have since moved away since Baisakh 2063.
Are there any members of your household who lived here in the past 10 years but who have since moved away?
NO 2 (GO TO 101)
DON'T KNOW 8 (GO TO 101)
23. MIGRANTS: Please give me the names of the persons who are living outside of this household? AFTER LISTING THE NAMES AND RECORDING THE SEX FOR EACH PERSON, ASK QUESTIONS 25-28 FOR EACH PERSON.
24. SEX: Is (NAME) male or female?
FEMALE 2
25. MONTH AND YEAR MOVED AWAY: In what month and year did (NAME) move away?
YEAR ___
26. AGE: How old was (NAME) when s/he moved away? IF 95 OR MORE, RECORD '95'. IF AGE LESS THAN 1 RECORD '00'.
27. REASON FOR MOVING: What was the main reason that (NAME) moved away?
STUDY 2
MARRIAGE 3
ACCOMPANY FAMILY 4
SECURITY 5
OTHER (SPECIFY) ___ 6
DON'T KNOW 8
28. PLACE TRAVELLED TO: Where has (NAME) travelled to? IF INDIA AND NEPAL, ASK FOR THE NAME OF THE CITY AND CODE; IF OTHER THAN INDIA OR NEPAL ASK FOR THE NAME OF THE COUNTRY, RECORD THE CODES AS PROVIDED
INDIA 2 ___
OTHER COUNTRY 3 ___
DON'T KNOW 998
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) ___ (GO TO 103)
102. What is the main source of water used by your household for other purposes such as cooking and handwashing?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
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
OTHER (SPECIFY) ___ 96
103. Where is that water source located?
IN OWN YARD/PLTO 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. CHECK 101 AND 102: CODE '14' OR '21'
NO (GO TO 107)
106. 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
107. Do you do anything to the water to make it safer to drink?
NO 2 (GO TO 109)
DON'T KNOW 8 (GO TO 109)
108. What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED.
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) ___ X
DON'T KNOW Z
109. What kind of toilet facility do members of your household usually use? IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEHWERE ELSE 14
FLUSH DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 113)
OTHER (SPECIFY) ___ 96
110. Do you share this toilet facility with other households?
NO 2 (GO TO 112)
111. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
112. Where is this toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE 3
113. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 116)
OTHER (SPECIFY) ___ 96
114. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (GO TO 116)
OUTDOORS 3 (GO TO 116)
OTHER (SPECIFY) ___ 6 (GO TO 116)
115. Do you have a separate room which is used as a kitchen?
NO 2
116. How many rooms in this household are used for sleeping?
117. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 119)
118. How many of the following animals does this household own? IF NONE, RECORD '00' IR 95 OR MORE, RECORD 95. IF UNKNOWN, RECORD '98'.
Milk cows or bulls?
Buffalo?
Horses, donkeys, or mules?
Goats?
Sheep?
Chicken or other poultry?
Ducks?
Pigs?
Yaks?
119. Does any member of this household own any agricultural land?
NO 2 (GO TO 121)
120. How many bigha/ropani of agricultural land do members of this household own? IF 95 OR MORE, CIRCLE '950'.
ROPANI 2 ___. ___
95 OR MORE BIGHA/ROPANI 950
DON'T KNOW 998
121. Does your household have:
a) Electricity?
b) A radio?
c) A television?
d) A non-mobile telephone?
e) A computer?
f) A refrigerator?
g) A table?
h) A chair?
i) A bed?
j) A sofa?
k) A cupboard?
l) A clock?
m) A fan?
n) A invertor?
o) A dhiki/janto?
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
122. Does any member of this household own:
a) A watch?
b) A mobile phone?
c) A bicycle/rickshaw?
d) A motorcycle or motor scooter?
e) An animal-drawn cart?
f) A car/truck/tractor?
g) A three wheel tempo?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
123. Does any member of this household have a bank account/cooperative or other savings account?
NO 2
124. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?
WEEKLY 2
MONTHLY 3
LESS OFTEN THAN ONCE A MONTH 4
NEVER 5
127. Does your household have any mosquito nets?
NO 2 (GO TO 128A)
128. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
128A. How can you protect yourself from mosquito bites?
USING REPELLENT CREAM B
USING COILS C
USING GOODNIGHT MAT/LIQUID D
TAKE INJECTION E
ELECTRIC BAT TO KILL MOSQUITOS F
SPRAY INSECTICIDES G
USE FAN H
PROPER SANITATION I
OTHER (SPECIFY) ___ X
DON'T KNOW Z
128B. Have you heard about Lymphatic Filariasis (Hattipaile)?
NO 2 (GO TO 128D)
128C. How does Lymphatic Filariasis (Hattipaile) transmit?
FROM CONTAMINATED FOOD B
CURSE FROM GOD C
OTHER (SPECIFY) ___ X
DON'T KNOW Z
128D. How long does it take to reach the nearest government health facility from your house?
DON'T KNOW 998
ADDITIONAL HOUSEHOLD CHARACTERISTICS
139. We would 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?
OBSERVED, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (GO TO 142)
NOT OBSERVEED, NO PERMISSION TO SEE 4 (GO TO 142)
NOT OBSERVED, OTHER REASON 5 (GO TO 142)
140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.
WATER IS NOT AVAILABLE 2
141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.
ASH, MUD, SAND B
NONE Y
142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION.
THATCH/PALM LEAF 12
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.
CANE/PALM/TRUNKS 12
MUD/SAND 13
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
REUSED WOOD 25
METAL/GALVANIZED SHEET 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
145. 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? TEST SALT FOR IODINE.
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) ___ 6
145AA. Now I would like to ask you about food insecurity that your household might have faced during the past 12 months.
145A. In the past 12 months, how frequently did you worry that your household would not have enough food?
RARELY 2
SOMETIMES 3
OFTEN 4
145B. In the past 12 months, how often were you or any household member not able to eat the kinds of foods you preferred because of a lack of resources?
RARELY 2
SOMETIMES 3
OFTEN 4
145C. In the past 12 months, how often did you or any household member have to eat a limited variety of foods due to lack of resources?
RARELY 2
SOMETIMES 3
OFTEN 4
145D. In the past 12 months, how often did you or any household member have to eat some foods that you really did not want to eat because of a lack of resources to obtain other types of foods?
RARELY 2
SOMETIMES 3
OFTEN 4
145E. In the past 12 months, how often did you or any household member have to eat a smaller meal than you felt you needed because there was not enough food?
RARELY 2
SOMETIMES 3
OFTEN 4
145F. In the past 12 months, how often did you or any household member eat fewer meals in a day because of lack of resources to get food?
RARELY 2
SOMETIMES 3
OFTEN 4
145G. In the past 12 months, how often was there with no food to eat of any kind in your household because of lack of resources to get food?
RARELY 2
SOMETIMES 3
OFTEN 4
145H. In the past 12 months, how often did you or any household member go to sleep at night hungry because there wasn't enough food?
RARELY 2
SOMETIMES 3
OFTEN 4
145I. In the past 12 months, how often did you or any household member go a whole day and night without eating anything because there was not enough food?
RARELY 2
SOMETIMES 3
OFTEN 4
MINUTES ___
COMMENTS ABOUT INTERVIEW:
______
COMMENTS ON SPECIFIC QUESTIONS:
____
ANY OTHER COMMENTS:
____
SUPERVISOR'S OBSERVATIONS
____