Data Cart

Your data extract

0 variables
0 samples
View Cart

India round 4 - Household Questionnaire

001a. Your ID: {your_name}

Is this your ID?

[] Yes
[] No

001b. Enter your ID below.

Please record your ID

002a. Current date and time.

Is this date and time correct?

[] Yes
[] No

002b. Record the correct date and time.

The date must be between 2018-01-01 and 2019-01-01.

003a. District

003b. Tehsil / Taluk

003c. City / Town / Village

004. Enumeration Area

005. Structure number

Please record the structure number from the household listing form.

006. Household number

Please record the household number from the household listing form.

007. CHECK: Have you already sent a form for this structure and household?

DO NOT DUPLICATE ANY FORM UNLESS YOU ARE CORRECTING A MISTAKE IN AN EARLIER FORM.

[] Yes
[] No

WARNING: Contact your supervisor before sending this form again.

008. CHECK: Why are you resending this form?

Choose all that apply.

[] There are new household members on this form
[] I am correcting a mistake made on a previous form
[] The previous form disappeared from my phone without being sent
[] I submitted the previous form and my supervisor told me that it was not received
[] Other reason(s)

WARNING: Each household should have ONLY ONE household roster with all household members listed on the same form.

Please contact your supervisor before sending this form.

009a. Is a member of the household and competent respondent present and available to be interviewed today?

[] Yes
[] No

009b. Did this household participate in a previous PMA2020 survey?

[] Yes
[] No
[] Do not know
[] No response

INFORMED CONSENT

Find a competent member of the household. Read the greeting on the following screen.

Namaskar! My name is ____________________________________ and I am working for the IIHMR University Jaipur in collaboration with local Partners. I belong to this/nearby village. We are conducting a local survey that asks about your family and family members. Post to that we would also ask different questions from women aged between 15-49 years, which would help to identify gaps in family planning and health services that affect regular availability and quality of information, services, and products. This survey is conducted across Rajasthan. From every enumeration area 35 households have been selected and in this extension your house is randomly selected. Though we would very much appreciate your participation in the survey, your refusal to take part in this survey will have no repercussions on you. Information provided by you would help us inform the government to better plan health services. As such there is no risk however; there may be a distress among participants to share information on personal topics. If you agree to take part in this study, it will not benefit you directly. However, we believe that information gathered in this study will help us and other groups like us to develop programs that will improve the lives of men and women in communities in Rajasthan and around India so we hope that you would take part in this survey. Whatever information you provide will be kept confidential and only our research team will have access to it. We will never use your name while analyzing the data. The tracking sheet and the database with your responses will be kept on password-protected computers and on a secure server. Participation in this study is entirely voluntary, if you do not wish to answer any question feel free to inform me and I would skip to the next question. You can choose not to participate at all or to end the interview at any point. The survey usually takes between 20 to 30 minutes to complete.
If you have any questions about the study and your right as a research participant, you may ask me now or you may also contact Dr. Anoop Khanna at IIHMR University, in Jaipur, Rajasthan at +91-141-3924738.

010a. Provide a paper copy of the Consent Form to the respondent and explain it. Then, ask: May I begin the interview now?

[] Yes
[] No

010b. Respondent's signature

Checkbox

[] NA

WARNING: the respondent has not signed or checked the box, despite agreeing to be interviewed in the previous question. To conduct the survey, the respondent must sign or touch the checkbox.

You may go back to obtain a signature or check the box or you should go back to the previous question to indicate the respondent does not want to be interviewed.

010c. Interviewer's ID: {your_name}

Mark your name as a witness to the consent process.

[] NA

010c. Interviewer's ID

Please record your ID as a witness to the consent process. You previously entered "{name_typed}."

That is not what you entered for your name earlier in this survey.

Section 1 - Household Roster

I am now going to ask a series of questions about each usual member of the household or anyone who slept in the house last night.

Household member

101. Name of household member / visitor

Start with the head of the household.

101a. Is this person the respondent?

[] NA

102. What is {firstname}'s relationship to the head of household?

[] Head
[] Wife/Husband
[] Son/Daughter
[] Son/Daughter-in-law
[] Grandchild
[] Parent
[] Parent in law
[] Brother/Sister
[] House help
[] Other
[] Do not know
[] No response

103. Is {firstname} male or female?

[] Male
[] Female

104. How old was {firstname} at their last birthday?

If less than 1 year old, record 0

Age must be less than 130 and greater than 0.

105. What is {firstname}'s current marital status?

If not married, probe to determine if they have ever been married and, if so, if they are divorced/separated, or widowed.

[] Married
[] Living with a partner
[] Divorced / separated
[] Widow / widower
[] Never married
[] No response

106. Does {firstname} usually live here?

[] Yes
[] No
[] No response

107. Did {firstname} stay here last night?

[] Yes
[] No
[] No response

ERROR: Members on household roster must usually live here or must have stayed here last night.

Go back and remove this household member.

LCL_101. What is the religion of {firstname}?

[] Hindu
[] Muslim
[] Christian
[] Sikh
[] Buddhist/Neo-Buddhist
[] Jain
[] Jewish
[] Parsi/Zoroastrian
[] No religion
[] Other
[] No response

LCL_102. What is the caste of {firstname}?

[] Scheduled Caste (SC)
[] Scheduled Tribe (ST)
[] Other Backward Caste (OBC)
[] General
[] Do not know
[] No response

This person IS NOT eligible for the female respondent questionnaire.

This person IS eligible for the female respondent questionnaire.

108. Are there any other usual members of your household or persons who slept in the house last night?

[] Yes
[] No

There are other members of the household. Move forward and select "Add Group"

There are no other members of the household. Move forward and select "Do Not Add"


ERROR: There is no household head.

Go back, select a head.

For each member, check that the relationship to the household head is accurate.

ERROR: There are {heads} household heads selected:
{head_name_joined}

Go back, select only one head.

For each member, check that the relationship to the household head is accurate.

The respondent must be in the roster. Only one person in the roster can be marked as the respondent. Go back and make sure that only one person is selected as the respondent.

You entered the following household members: {names}

109. READ THIS CHECK OUT LOUD: There are {num_HH_members} household members who are named {names}. Is this a complete list of the household members?

Remember to include all children in the household.

Go back and update the roster.

[] Yes
[] No

Section 2 - Household Characteristics

Now I would like to ask you a few questions about the characteristics of your household.

201. Please tell me about items that your household owns. Does your household have:

Read out all types and select all that apply. Scroll to bottom to see all choices.

If an item is reported broken but said to be out of use only temporarily, select the item. Otherwise, do not select the item.

Cannot select 'no response' or 'none of the above' with other options.

[] Electricity
[] Mattress
[] Pressure cooker
[] Chair
[] Cot / bed
[] Table
[] Electric fan
[] Radio / transistor
[] BandW television
[] Colour television
[] Sewing machine
[] Mobile telephone
[] Land line telephone
[] Internet
[] Computer
[] Refrigerator
[] Air conditioner / cooler
[] Washing machine
[] Watch / clock
[] Bicycle
[] Motorcycle / scooter
[] Animal-drawn cart
[] Car
[] Water pump
[] Thresher
[] Tractor
[] None of the above
[] No response

Check here to acknowledge you considered all options.

[] NA

202a. Does this household own any livestock, herds, other farm animals, or poultry?

These livestock can be kept anywhere, not necessarily on the homestead.

[] Yes
[] No
[] No response

202b. How many of the following animals does this household own?

The household can keep the livestock anywhere, but must own the livestock recorded here.

Zero is a possible answer. Enter -88 for do not know. Enter -99 for no response.

Cows / bulls / buffaloes

Error with COWS / BULLS / BUFFALOES

Camels

Error with CAMELS

Horses / donkeys / mules

Error with HORSES / DONKEYS / MULES

Goats

Error with GOATS

Sheep

Error with SHEEP

Chickens / ducks

Error with CHICKENS / DUCKS

Other

OTHER invalid

Section 3 - Household Observation

Please observe the floors, roof and exterior walls.

301. Main material of the floor

Observe.

[] Mud / clay / earth
[] Sand
[] Dung
[] Raw wood planks
[] Palm / bamboo
[] Brick
[] Stone
[] Parquet / finished wood
[] Vinyl / asphalt
[] Ceramic tile
[] Cement
[] Carpet
[] Polished stone / marble / granite
[] Other
[] No response

302. Main material of the roof

Observe.

[] No roof
[] Thatch / palm leaf / reed / grass
[] Mud
[] Sod / mud and grass mixture
[] Plastic / polythene sheeting
[] Rustic mat
[] Palm / bamboo
[] Raw wood planks / timber
[] Unburnt brick
[] Loosely packed stone
[] Metal / GI
[] Wood
[] Calamine / cement fiber
[] Asbestos sheets
[] RCC / RBC / Cement / Concrete
[] Roofing shingles
[] Tiles
[] Slate
[] Burnt brick
[] Other
[] No response

303. Main material of the exterior walls

Observe.

[] No walls
[] Cane / palm / trunks / bamboo
[] Mud
[] Grass / reeds / thatch
[] Bamboo with mud
[] Stone with mud
[] Plywood
[] Cardboard
[] Unburnt brick
[] Raw wood / reused wood
[] Cement / concrete
[] Stone with lime / cement
[] Burnt brick
[] Cement blocks
[] Wood planks / shingles
[] GI / metal / asbestos sheets
[] Other
[] No response

Section 4 - Water Sanitation and Hygiene

Now I would like to ask you a few questions about water, sanitation and hygiene.

401. 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, fixed place
[] Observed, mobile
[] Not observed, not in dwelling/yard/plot
[] Not observed, no permission to see
[] Not observed, other reason
[] No response

401c. At the place where the household washes their hands, observe if:

Check all that apply.

Cannot select 'none of the above' with other options.

[] Soap is present
[] Stored water is present
[] Running water is present
[] Handwashing area is near a sanitation facility
[] None of the above

402. Which of the following water sources does your household use on a regular basis for any part of the year for any purpose?

Read out all types and check all that are used. Scroll to bottom to see all choices.

Cannot select 'no response' with other options.

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

Check here to acknowledge you considered all options.

[] NA

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

Selections from 402:
{source_labels}

Read out 402 selections only.

You did not select that choice in 402.

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

404. What is the main source of water used by your household for other purposes such as cooking and hand washing?

Selections from 402:
{source_labels}

Read out 402 selections only.

You did not select that choice in 402.

[] Piped Water: Piped into dwelling/indoor
[] Piped Water: Pipe to yard/plot
[] Piped Water: Public tap/standpipe
[] Tube well or borehole
[] Dug Well: Protected Well
[] Dug Well: Unprotected Well
[] Water from Spring: Protected Spring
[] Water from Spring: Unprotected Spring
[] Rainwater
[] Tanker Truck
[] Cart with Small Tank
[] Surface water (River / Dam / Lake / Pond / Stream / Canal / Irrigation Channel)
[] Bottled Water
[] Sachet Water
[] No response

405. You mentioned that you used {main_drinking_water_lab}. At any time of the year, does your household use water from this source for:

[] Drinking
[] Cooking
[] Livestock
[] Gardening / agriculture
[] Business venture
[] Washing
[] No response

406. How many months out of the year is {main_drinking_water_lab} usually available:

Zero is a possible answer. Please record the number of completed months. Enter -88 for Do Not Know, -99 for No Response

407. At a time of year when you expect to have {main_drinking_water_lab}, is it usually available?

[] Yes, always
[] No, intermittent and predictable
[] No, intermittent and unpredictable
[] No response

408. How long does it take to go to the {main_drinking_water_lab}, and come back?

Zero is a possible answer. Convert answer to minutes. Includes waiting time in line. Enter -88 for do not know, -99 for no response.

409. Do members of your household use any of the following toilet facilities?

Read out all types. Check all that are used. Scroll to bottom to see all choices.

Cannot select 'no response' with other options.

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

Check here to acknowledge you considered all options.

[] NA

410. What is the main toilet facility used by members of your household?

Selections from 409:
{sanitation_labels}

The main facility must be selected in 409.

You did not select that choice in the previous question.

[] Flush/pour flush toilets connected to: Piped sewer system
[] Flush/pour flush toilets connected to: Septic tank
[] Flush/pour flush toilets connected to: Pit Latrine
[] Flush/pour flush toilets connected to: Elsewhere
[] Flush/pour flush toilets connected to: Unknown / Not sure / Do not know
[] Ventilated improved pit latrine
[] Pit latrine with slab
[] Pit latrine without slab / open pit
[] Composting toilet
[] Bucket
[] Hanging toilet /Hanging latrine
[] Other
[] No facility / bush / field
[] No response

SN_411.ii. When was the last time your {the_sanitation_lab} was emptied?

Probe: How many months or years ago?

If less than one month, select months.

[] X months ago
[] X years ago
[] Never emptied
[] Do not know
[] No response

Enter {sanitation_empty_lab}:

If less than one month, enter 0 months.

SN_411.iii. The last time your {the_sanitation_lab} was emptied, who emptied it?

Probe: Was it emptied by household members or by neighbors or by a service provider?

[] By household members or neighbors
[] By a service provider
[] Other
[] Do not know
[] No response

SN_411.iv. The last time your {the_sanitation_lab} was emptied, where were the contents emptied to?

[] To a covered and sealed hole (buried)
[] To an open drain or to a water body
[] To an open hole (not buried), open ground, bush, beach or to agricultural land
[] Taken away by the service provider to a treatment facility
[] Taken away by the service provider to do not know where
[] Other
[] Do not know
[] No response

SN_411.v. Where is your toilet facility located?

{the_sanitation_lab}

[] In own dwelling
[] In own yard / plot
[] Elsewhere
[] No response

411. How often does your household typically use:

{the_sanitation_lab}

Regular practices at the household only.

[] Always
[] Most of the time
[] Occasionally
[] No response

412a. Do you share this toilet facility with other households or the public?

{the_sanitation_lab}

[] Not shared
[] Shared with less than ten households
[] Shared with ten or more households
[] Shared with the public
[] No response

412b. Enter the number of households that share this facility (including your own).

{the_sanitation_lab}

Must be between 2 and 9.

If 10 or greater, move back to 412a and choose "Shared with 10 or more households."

Enter -99 for no response.

413. How many people within your household regularly use the bush / field at home or at work?

There are {num_HH_members} people in this household.

Enter -88 for do not know, -99 for no response.

Must be between 0 and the number of household members.

414. For all children under age 5: what methods, if any, does your household use to dispose of children's waste?

PROBE: Other methods?

Do not read the possible responses out loud.

[] Children use a latrine / toilet
[] Leave waste where it is
[] Bury waste in field / yard
[] Dispose of waste in latrine / toilet
[] Dispose of waste with rubbish / garbage
[] Dispose of waste with waste water
[] Use it as manure
[] Burn it
[] Do not know
[] No response

WARNING: The respondent entered zero for the previous question, 413, but listed open defecation as a household sanitation facility in 409.

Thank the respondent for his/her time.

The respondent is finished, but there is still more for you to complete outside the home.

Location and Questionnaire result

096. Location

Take a GPS point near the entrance to the household. Record location when the accuracy is smaller than 6 m.

097. How many times have you visited this household?

[] First time
[] Second time
[] Third time

098. In what language was this interview conducted?

[] English
[] Hindi
[] Other

099. Questionnaire Result

Record the result of the questionnaire.

Check answer to 009 and the consent.

[] Completed
[] No household member at home or no competent respondent at home at time of visit
[] Postponed
[] Refused
[] Partly completed
[] Dwelling vacant or address not a dwelling
[] Dwelling destroyed
[] Dwelling not found
[] Entire household absent for extended period