LONG HOUSEHOLD QUESTIONNAIRE
PROVINCE
SINDH 2
NWFP 3
BALOCHISTAN 4
FATA 5
DISTRICT __
TEHSIL __
CLUSTER NUMBER __
HOUSEHOLD NUMBER ___
IS HOUSEHOLD SELECTED FOR:
WOMAN 2
VERBAL AUTOPSY 3
WOMAN AND VERBAL AUTOPSY 4
NAME OF HOUSEHOLD HEAD ___
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __
INTERVIEWERS NAME ___
RESULT* __
1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ___
NEXT VISIT:
DATE ______
TIME _______
FINAL VISIT
DAY __
MONTH __
YEAR ___
INT. NUMBER ___
RESULT* __
DEATHS UNDER 5/SBs FROM Q. 38 __
FEMALE DEATHS AGE 12-49 FROM Q. 39 __
LINE NO. OF RESPONDENT __
LANGUAGE OF QUESTIONNAIRE: URDU
FIELD EDITOR
NAME__
DATE__
OFFICE EDITOR__
KEYED BY __
SIGNATURE OF INTERVIEWER: _____
DATE: __
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
Now we would like some information about the people who usually live in your household or who are staying with you now.
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 NAMES, RELATIONSHIP AND SEX FOR EACH PERSON, ASK Qs. 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK QUESTIONS IN COLUMNS 5-11 FOR EACH PERSON.
3) RELATIONSHIP TO HEAD OF THE HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 BROTHER/SISTER IN LAW
10 NIECE/NEPHEW
11 GRAND PARENTS
12 AUNTS/UNCLES
13 OTHER RELATIVE
14 ADOPTED/FOSTER/STEPCHILD
15 NOT RELATED
16 DOMESTIC SERVANT
98 DON'T KNOW
FEMALE 2
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
7) How old is (NAME)?
IF LESS THAN 1 YEAR, WRITE 00
IF AGE 96 YEARS OR MORE, WRITE 96
IF AGE 12 OR OLDER
MARTIAL STATUS
8) What is (NAME'S) current marital status?
2 WIDOWED
3 DIVORCED/SEPARATED
4 NEVER MARRIED
9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 12-49 WHO ARE MARRIED, WIDOWED OR DIVORCED OR SEPARATED
EDUCATION
10) Has (NAME) ever attended school?
NO 2 (GO TO 15)
11) What is the highest class of school (NAME) completed?
IF AGE 5-24 YEARS
CURRENT SCHOOLING
12) Did (NAME) attend school at any time during the 2006 year?
NO 2 (GO TO 14)
13) During this school year, what class/grade is/was (NAME) attending?
SCHOOLING DURING LAST YEAR
14) Did (NAME) attend school at any time during the previous year 2005?
NO 2
IF AGE 0-17 YEARS
SURVIVORSHIP OF BIOLOGICAL PARENTS
15) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
16) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
FOR ALL AGES
REGISTRATION WITH NADRA
17) Has (NAME) been registered with NADRA?
IF YES- PROBE: Does (NAME) have NIC card or name entered onto a 'bay' form, or nothing at all?
NAME ON 'BAY' FORM 2
NEITHER OF THE ABOVE 3
DOES NOT KNOW 8
Just to make sure that I have a complete household listing:
2A) Are there any other persons such as a small child 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 slept here last night, who have not been listed?
NO __
IF NO MORE MEMBERS, GO TO COLUMN 5.
INFORMATION ABOUT BIRTHS AND DEATHS IN THE HOUSEHOLD IN THE PREVIOUS 3 YEARS.
18) Now I would like to ask you about all the births that occurred in this household in the last 3 years, whether they were born alive or dead. Since January 2003, did any woman who was a usual resident of this household at that time give birth? I am interested in any birth, even stillbirths and children who did not survive.
NO 2 (GO TO 27)
19) How many births occurred in this household in the last 3 years?
21) What are the names of the babies born in the last three years?
IF STILL BORN, WRITE 'BABY'
GIRL 2
23) In what month and yeah was (NAME) born?
IF MONTH DON'T KNOW, RECORD '98'
YEAR __
NO 2 (NEXT)
NO 2 (NEXT)
26) LINE NUMBER FROM HOUSEHOLD ROSTER (RECORD '00' IF CHILD NOT LISTED IN HH ROSTER)
27) Now I would like to ask you about any death that occurred in this household in the last 3 years. Since January 2003, God forbid, has any usual member of this household died?
NO 2 (GO TO 38)
28) How many deaths occurred to usual residents in this household in the last three years?
30) What were the names of the people who died in the last three years?
31) Was (NAME) male or female?
FEMALE 2
32) In what month and year did (NAME) die?
IF MONTH DON'T KNOW, RECORD '98'
YEAR ____
33) How old was (NAME) when he/she died?
RECORD DAYS IF LESS THAN 1 MONTH; MONTHS IF LESS THAN 2 YEARS' OR YEARS
MONTHS 2 ___
YEARS 3 ___
34) CHECK 31 AND 33: WAS THIS A WOMAN AGE 12-49 WHEN SHE DIED?
NO 2 (NEXT)
35) Was (NAME) pregnant when she died?
NO 2
36) Did (NAME) die during childbirth?
NO 2
37) Did (NAME) die within 6 weeks after delivery?
NO 2 (NEXT)
38) CHECK COLS. 32, 33, AND 23/24: NUMBER OF DEATHS TO CHILDREN UNDER 5 YEARS AND STILLBIRTHS IN 2005 OR AFTER
39) CHECK COLUMN 34 AND 32: NUMBER OF DEATHS TO WOMEN AGE 12-49 YEARS OLD IN 2003 OR AFTER
101) What is the main source of drinking water for members of your household?
PIPED WATER TO YARD/PLOT 12 (GO TO 103)
PUBLIC TAP/STAND PIPE 13
TUBE WELL OR BOREHOLE 21
HAND PUMP 22
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL) 81
BOTTLED WATER 91
OTHER (SPECIFY)___ 96
102) How long does it take to go there, get water, and come back?
ON PREMISES 996
DON'T KNOW 998
103) Do you treat your water in any way to make it safer to drink?
NO 2
DON'T KNOW 8
104) What do you usually do to the water to make it 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
105) What kind of toliet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO SOMEWHERE ELSE 13
FLUSH, DON'T KNOW WHERE 14
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
OPEN PIT 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61
OTHER (SPECIFY) ___ 96
106) Do you share this toilet facility with other households?
NO 2
107) Does your household have:
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
NO 2
108) What type of fuel does your household mainly use for cooking?
CYLINDER GAS 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP 09
ANIMAL DUNG 10
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY) ___ 96
109) MAIN MATERIAL OF THE FLOOR:
RECORD OBSERVATION
CERAMIC TILES 32
MARBLE 33
CEMENT 34
CARPET 35
BRICKS 36
MATS 37
OTHER (SPECIFY) ____ 92
110) MAIN MATERIAL OF THE ROOF:
RECORD OBSERVATION.
T-IRON/WOOD/BRICK 32
REINFORCED BRICK CEMENT/RCC 33
111) MAIN MATERIAL OF THE WALLS:
RECORD OBSERVATION.
BAMBOO/STICKS/MUD 12
PLYWOOD SHEETS 22
CARTON/PLASTIC 23
FINISHED WALLS
STONE BLOCKS 31
BAKED BRICKS 32
CEMENT BLOCKS/CEMENT 33
TENT 34
112) How many rooms in this household are used for sleeping?
113) Is this house rented, rent-free, mortgaged, or owned by a member of the household?
RENT-FREE 2
MORTGAGED 3
OWNED 4
OTHER 6
114) Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
115) Does any member of this household own any land that can be used for agriculture?
NO 2
116) Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 118)
117) How many of the following animals does this household own?
IF NONE, WRITE '00'. IF LESS THAN 95, WRITE '95'. IF UNKNOWN, WRITE '98'
COWS/BULLS __
CAMELS __
DONKEY/MULES/HORSES __
GOATS __
SHEEP __
CHICKENS __
118) Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 126)
119) How many mosquito nets does your household have?
ASK THESE QUESTIONS FOR ONLY TWO BEDNETS:
120) When you got the net, was it already treated with an insecticide to kill or repel mosquitos?
NO 2
NOT SURE 8
121) Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?
NO 2 (GO TO 125)
DON'T KNOW 8 (GO TO 125)
122) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'
25 OR MORE MONTHS 95
NOT SURE 98
123) Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 125)
NOT SURE 8 (GO TO 125)
124) Who slept under this mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. ___
125) GO BACK TO 120 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 126
126) Does your household do anything (else) to avoid mosquitos?
NO 2 (GO TO 128)
127) What do you do?
CIRCLE ALL MENTIONED.
MATS B
SPRAY C
ELECTRIC SPRAY REPELLANT D
INSECT REPELLANT E
OTHER (SPECIFY) ____ X
128) Do you have any medicines for treating malaria in your house now?
NO 2
DOES NOT KNOW 8