PROVINCE/REGION
SINDH 2
KPK 3
BALOCHISTAN 4
GB 5
ICT 6
DISTRICT __
TEHSIL __
CLUSTER NUMBER __
HOUSEHOLD NUMBER __
SMALL CITY 2
TOWN 3
RURAL 4
HOUSEHOLD SELECTED FOR MEN INTERVIEW
NO 2
PLACE NAME __
NAME OF HOUSEHOLD HEAD __
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS
DATE
INTERVIEWER'S NAME
RESULT*
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME 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
FINAL VISIT:
DAY
MONTH
YEAR
INT. NUMBER
RESULT*
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME 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
LANGUAGE OF QUESTIONNAIRE: ENGLISH
TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __
FIELD EDITOR:
NAME
DATE
OFFICE EDITOR __
KEYED BY __
Asalum-o-Alaikum. My name is _________. I am working with National Institute of Population Studies. We are conduction a survey about health all over Pakistan. The information we collect will help the government to plan health services. Your household is 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.
Do you have any questions?
May I begin the interview now?
SIGNATURE OF INTERVIEWER: __________
DATE: ____
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
Now I would like to ask you some information about the people who usually live in your household or who are staying with you now.
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 AS QUESTIONS IN COLUMNS 5-25 FOR EACH PERSON.
2A) Just to make sure that I have a complete household 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 slept here last night, who have not been listed?
NO
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/UNCLE
13 = OTHER RELATIVE
14 = ADOPTED/FOSTER/STEPCHILD
16 = DOMESTIC SERVANT
98 = DON'T KNOW
4) SEX
Is (NAME) male or female?
FEMALE 2
5) RESIDENCE
Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
7) AGE
How old is (NAME)?
IF LESS THAN 1 YEAR, WRITE '00'.
IF AGE 95 YEARS OR MORE, WRITE '95'.
MARITAL STATUS IF AGE 15 YEARS OR OLDER
8) What is (NAME'S) current marital status?
2 WIDOWED
3 SEPARATED/DIVORCED
4 NEVER MARRIED
9) ELIGIBILITY
CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 YEARS WHO ARE MARRIED, WIDOWED, OR DIVORCED OR SEPARATED
10) CIRCLE LINE NUMBER OF ELIGIBLE MAN AGE 15-49 WHO ARE MARRIED, WIDOWED, OR DIVORCED OR SEPARATED
11) CIRCLE LINE NUMBER OF ELIGIBLE CHILD AGE 0-5
EDUCATION IF AGE 5 YEARS OR OLDER
12) Has (NAME) ever attended school?
NO 2 (GO TO 17)
13) What is the highest class (NAME) completed?
01 CLASS 1
02 CLASS 2
03 CLASS 3
04 CLASS 4
05 CLASS 5
06 CLASS 6
07 CLASS 7
08 CLASS 8
09 CLASS 9
10 MATRIC, CLASS 10
11 CLASS 11
12 CLASS 12
13 CLASS 13
14 CLASS 14
15 CLASS 15
16 MASTER'S DEGREE OR MBBS, PhD, MPHIL, BCs (4 YEARS)
98 DON'T KNOW
CURRENT SCHOOLING IF AGE 5-24 YEARS
14) Did (NAME) attend school/college/university at any time during the 2012 year?
NO 2 (GO TO 16)
15) During this year, which class/grade is (NAME) attending?
01 CLASS 1
02 CLASS 2
03 CLASS 3
04 CLASS 4
05 CLASS 5
06 CLASS 6
07 CLASS 7
08 CLASS 8
09 CLASS 9
10 MATRIC, CLASS 10
11 CLASS 11
12 CLASS 12
13 CLASS 13
14 CLASS 14
15 CLASS 15
16 MASTER'S DEGREE OR MBBS, PhD, MPHIL, BCs (4 YEARS)
98 DON'T KNOW
16) What is the main reason (NAME) is not attending school?
REASONS FOR NOT ATTENDING SCHOOL:
02 TRANSPORT NOT AVAILABLE
03 FURTHER EDUCATION NOT NECESSARY
04 REQUIRED FOR HOUSEHOLD/FARMA WORK
05 GOT MARRIED
06 COSTS TOO MUCH
07 NOT INTERESTED IN STUDIES
08 REPEATED FAILURE
09 DID NOT GET ADMISSION
10 NOT SAFE
11 NEED TO WORK TO EARN
96 OTHER
98 DON'T KNOW
SURVIVORSHIP OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS
17) Is (NAME)'s natural mother alive?
NO 2 (GO TO 19)
DON'T KNOW 8 (GO TO 19)
18) Does (NAMES)'s natural 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'
19) Is (NAME)'s natural father alive?
NO 2 (GO TO 22)
DON'T KNOW 8 (GO TO 22)
20) Does (NAME) have NIC card or name entered onto a 'bay' form, or nothing at all?
IF NAME IS ON BAY FORM, HAS (NAME) BIRTH CERTIFICATE?
IF NEITHER NIC NOR NAME ON NIC BAY FORM, HAS (NAME) BIRTH CERTIFICATE?
2 NAME ON 'BAY' FORM AND HAVING BIRTH CERTIFICATE
3 NAME ON 'BAY' FORM AND HAVING NO BIRTH CERTIFICATE
4 ONLY BIRTH CERTIFICATE
5 NEITHER OF ABOVE
8 DOES NOT KNOW
MIGRATION FOR ALL USUAL MEMBERS
22) Was (NAME) born in this village/city?
NO 2
23) From where did (NAME) move to this village/city?
DISTRICT (IF RURAL) 2
OUTSIDE COUNTRY 3
24) In which year did (NAME) first move to this village/city?
(WRITE FOUR-DIGIT)
DON'T KNOW 9998
25) What was the primary reason for (NAME)'s move to this village/city?
02 ACCUMULATE SAVING
03 TRANSFERRED
04 SCHOOLING
05 BETTER INFRASTRUCTURE
06 ACCOMPANIED FAMILY
07 JOIN THE FAMILY
08 ESCAPE DROUGHT/FLOOD
09 ESCAPE WAR/VIOLENCE
10 ESCAPE OTHER NATURAL DISASTER
11 MARRIAGE
12 SINCE CHILDHOOD
13 BIRTH FO POSTPARTUM
96 OTHERS
98 DON'T KNOW
OUT MIGRATION
26) Now I would like to ask you about members of this household who have lived here in the past 10 years but have since moved away.
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 34)
DON'T KNOW 8 (GO TO 34)
28) 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 31-34 FOR EACH PERSON
FEMALE 2
30) In what month and year did (NAME) move away?
DON'T KNOW MONTH 98
YEAR ____
DON'T KNOW YEAR 9998
31) How old was (NAME) when he/she moved away?
IF AGE 95 OR MORE, RECORD '95'.
IF LESS THAN 1 YEAR OLD, RECORD '00'.
DON'T KNOW 98
32) What was the main reason that (NAME) moved away?
02 ACCUMULATE SAVING
03 TRANSFERRED
04 SCHOOLING
05 BETTER INFRASTRUCTURE
06 ACCOMPANIED FAMILY
07 JOIN THE FAMILY
08 ESCAPE DROUGHT/FLOOD
09 ESCAPE WAR/VIOLENCE
10 ESCAPE OTHER NATURAL DISASTER
11 MARRIAGE
12 SINCE CHILDHOOD
96 OTHERS
33) Where has (NAME) travelled to?
IF OTHER CITY OF PAKISTAN, ASK FOR NAME OF CITY AND CODE. IF OTHER PART OF PAKISTAN, AS FOR NAME OF DISTRICT AND CODE. IF OTHER THAN PAKISTAN, ASK FOR NAME OF THE COUNTRY
CIRCLE THE CODES AS PROVIDED.
2 DISTRICT (IF RURAL)
3 OUTSIDE COUNTRY
NAME _____
DON'T KNOW 9998
34) CHECK THE IDENTIFICATION SECTION OF HOUSEHOLD QUESTIONNAIRE. IS HOUSEHOLD SELECTED FOR MEN INTERVIEW?
HOUSEHOLD NOT SELECTED (GO TO 101)
35) TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE
LOOK AT THE LAST DIGIT OF THE HOUSEHOLD NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE FEMALE RESPONDENTS ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. FOR EACH NON-ZERO NUMBER, THE IS THE COLUMN. YOU SHOULD GO TO THE CELL WHERE THE ROW AND COLUMN MEET; IS THE NUMBER OF THE SELECTED WOMAN FOR DOMESTIC VIOLENCE MODULE.
FOR EXAMPLE, IF THE HOUSEHOLD NUMBER IS '16', GO TO ROW '6'. IF THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 YEARS IN THE HOUSEHOLD, GO TO COLUMN '3'. FIND THE NUMBER IN THE BOX WHERE THE ROW MEETS THE COLUMN ('2'). NOW GO TO THE HOUSEHOLD SCHEDULE AND CIRCLE THE LINE NUMBER OF THE SELECTED WOMEN.
TABLE FOR SELECTION OF RESPONDENTS FOR SECTION ON DOMESTIC VIOLENCE MODULE:
HEADER FOR THE LEFT-HAND COLUMN: "LAST DIGIT OF THE HOUSEHOLD NUMBER (ROW)" (VALUES 0-9 BELOW THIS)
HEADER FOR TOP ROW OF TABLE: "TOTAL NUMBER OF ELIGIBLE WOMEN 15-49 YEARS IN THE HOUSEHOLD" (COLUMN)
COLUMNS WITH 1's, 2's, 3's, 4's, 5's, 6's, 7's, AND 8's FILL THE CELLS OF THE TABLE.
36) Line number of selected woman
(IF NO ELIGIBLE WOMAN WRITE '00' AND SKIP TO 101)
SECTION 1. HOUSEHOLD CHARACTERISTICS
101) How often does anyone smoke cigarette/huqa/berri or pipe inside your house? Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5
102) What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 105)
PUBLIC TAP/STANDPIPE 13
HAND PUMP 22
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
FILTRATION PLANT 62
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) _____ 96
103) Where is that water source located?
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104) How long does it take to go there, get water, and come back?
105) Do you do anything to the water to make it safer to drink?
NO 2 (GO TO 107)
DON'T KNOW 8 (GO TO 107)
106) What do you usually do to make the water safer to drink? Anything else>
CIRCLE 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
107) What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
VENTILATED IMPROVED
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 110)
OTHER (SPECIFY) 96
108) Do you share this toilet facility with other households?
NO 2 (GO TO 110)
109) How many other households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
110) Does your household have: for example:
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
NO 2
NO 2
111) 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
ANIMAL DUNG 10
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 114)
OTHER (SPECIFY) 96
112) Is the cooking usually done in this house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (GO TO 114)
OUTDOORS 3 (GO TO 114)
OTHER (SPECIFY) 6 (GO TO 114)
113) Do you have a separate room which is used as a kitchen?
NO 2
114) MAIN MATERIAL OF THE FLOOR
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
CHIPS/TERRAZZO 36
BRICKS 37
MATS 38
MARBLE 39
115) MAIN MATERIAL OF THE ROOF
THATCH/PALM LEAF 12
SOD/GRASS 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
REINFORCED BRICK CEMENT/RCC 32
METAL 33
WOOD/ T IRON/MUD 34
CALAMINE/CEMENT FIBER 35
CERAMIC TILES 36
CEMENT/RCC 37
ROOFING SHINGLES 38
116) MAIN MATERIAL OF EXTERIOR WALLS
CANE/PALM/TRUNKS 12
DIRT 13
MUD/STONES 14
BAMBOO/STICKS/MUD 15
CARTON/PLASTIC 22
BAMBOO WITH MUD 23
STONE WITH MUD 24
UNCOVERED ADOBE 25
PLYWOOD 26
CARDBOARD 27
REUSED WOOD 28
TENT 32
CEMENT 33
STONE WITH LIME/CEMENT 34
BRICKS 35
CEMENT BLOCKS 36
COVERED ADOBE 37
WOOD PLANKS/SHINGLES 38
117) How many rooms in this household are used for sleeping?
118) Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
119) Does any member of this household own any agriculture land?
NO 2 (GO TO 121)
120) How many acres or kanals of agricultural land do members of this household own?
IF 95 OR MORE, RECORD '950' IN BOX.
KANAL 2 ____
DON'T KNOW 9998
121) Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 123)
122) How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKNOWN, ENTER '98'.
123) Does any member of this household have a bank account?
NO 2
124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (GO TO 126)
DON'T KNOW 8 (GO TO 126)
125) Who sprayed the dwelling?
(CIRCLE ALL MENTIONED)
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY) X
DON'T KNOW Z
126) Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 131)
127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
128) How many of these mosquito nets are insecticide treated?
CIRCLE '0' IF ANSWER IS 'NONE'
IF 7 OR MORE, RECORD '7'
NUMBER OF NETS __
DON'T KNOW 8 (GO TO 131)
129) Do you usually soak the mosquito nets in a liquid that kill or repel mosquitos?
NO 2 (GO TO 131)
DON'T KNOW 8 (GO TO 131)
130) Generally, after how many months mosquito nets are soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'
25 OR MORE MONTHS 95
NOT SURE 98
131) Do you think that the use of insecticide treated nets can reduce the incidence of Malaria?
NO 2
NOT SURE 8
132) What else your household does to avoid mosquitos?
NO 2 (GO TO 134)
133) What do you do? Anything else?
(CIRCLE ALL MENTIONED)
MATS B
SPRAY C
ELECTRIC SPRAY REPELLENT D
INSECT REPELLENT E
INFRARED ELECTRIC DEVICE F
SMOKE G
MEMBRANCE H
OTHER (SPECIFY) X
134) Please show me where the members of your household most often was their hands?
OBSERVATION ONLY
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 2 (GO TO 201)
NOT OBSERVED, NO PERMISSION TO SEE 3 (GO TO 201)
NOT OBSERVED, OTHER REASON 4 (GO TO 201)
135) OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING
WATER IS NOT AVAILABLE 2
136) OBSERVATION ONLY:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANING AGENT
ASH, MUD, SAND B
NONE C
WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5
201) CHECK IDENTIFICATION SECTION OF HOUSEHOLD QUESTIONNAIRE
HOUSEHOLD SELECTED FOR MEN INTERVIEW
NO (END OF SECTION)
202) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 203. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).
203) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
NAME___
204) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OR BIRTH FROM PREGNANCY HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: what is (NAME)'s birth date?
MONTH__
YEAR__
205) CHECK 204:
CHILD BORN IN JANUARY 2007 OR LATER?
NO 2 (GO TO 204 FOR NEXT CHILD OF, IF NO MORE CHILDREN, GO TO 210)
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
CHILD NOT PRESENT 9994
REFUSED 9995
OTHER 9996
208) MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
NOT MEASURED 3
209) GO BACK TO 204 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 210.
WEIGHT AND HEIGHT MEASUREMENT FOR ELIGIBLE WOMEN
210) CHECK COLUMN 9 IN THE HOUSEHOLD SCHEDULE. RECORD THE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 211. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
211) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2
NAME___
NOT PRESENT 99994
REFUSED 99995
OTHER 99996
NOT PRESENT 9994
REFUSED 9995
OTHER 9996
214) PREGNANCY STATUS:
CHECK 234 IN WOMAN'S QUESTIONNAIRE OT ASK:
Are you pregnant?
NO 2
NOT PRESENT 4
NOT SURE/DON'T KNOW 8
215) GO BACK TO 212 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END OF HOUSEHOLD QUESTIONNAIRE