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Household Template 28 -Form Fill
Information
Q01
Unique Reference ID
Q02
State
Q03
District
Q04
Block
Q05
Cluster
Q06
Code of Village
Q07
Category
Diarrhoea/Pneumonia
TB
Kala Azar
Q08
Structure no
Q09
Household no
Q10
Name of the respondent
Q11
Child ID. as per HH list
Q12
No. of children under 5 years of age in HH
Q13
DOB of the child
Q14
Name of the child
Q15
Name of the Mother
Q16
Name of the Head of the Household
Q17
Phone Number
Q18
INTERVIEWER’S NAME
Q19
RESULT
completed
no household member at home or no competent respondent at home at time of visit
entire hh absent for extended period of time
postponed
Refused
household vacant
address not a household
dwelling destroyed
dwelling not found
others; (specify)
Household Roster
A01
Please give me the names of the persons who usually live in your household, starting with the head of the household.
A02
What is the relationship of (name) to the head of the household?
Head
Wife / Husband
Son / Daughter
Son-in-law/ Daughter-in-law
Grandson / Granddaughter
Father / Mother
Parent-in-law
Brother / Sister
Other relative
Adopted / foster / step child
Not related
Don’t know
A03
Is (name) male or female?
Male
Female
A04
How old is (name)?
A05
Please specify the id code of the mother of the child of age 0-14 years?
A06
Please specify the id code of the father of the child of age 0-14 years?
A07
What is (name)'s current marital status?
A08A
Can (name) read and write?
Yes
No
A08B
What is the Number of years of education (name) has completed?
A09A
Has (name) been sick in the past 15 days?
Yes
No
A09B
Did (name) see a health care provider for this illness?
Yes
No
A10A
Just to make sure that I have a complete listing. Are there any other persons such as small children or infants born in the last 60 months that we have not been listed?
Yes
No
A10B
Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?
Yes
No
A11
What is the religion of the head of the household?
Hindu
Muslim
Christian
Sikh
Buddhism
Jain
No Religion
Other (Specify_________)
A12
What is the caste/tribe of the head of the household?
General
Scheduled Caste
Scheduled Tribe
Other Backward Caste
Other (Specify)
Do Not Know / Can’t Say
A13
Do you have a BPL card or a Blue Ration Card?
Yes
No
A14
Did any usual residents of this household (including children) die since January 1, 2009?
Yes
No
A15
How many persons died?
A16
What (Was/Were) the name (s) of the person(s) who died?
A17
Was (NAME) a male or a female?
Male
Female
A18
How old was he/she when died?
A19
In what month and year did (NAME) die?
WHP Services
B01
Are you aware of the Sky health center / the place where you can consult a city doctor through a machine?
Yes
No
B02
how did you learn about it?
Relatives, friends and neighbors
Drum beating (Tom tom) / Mike Announcements
Local market/weekly
Pamphlets/posters
NGOs/community worker
Self Help Group/members
anm
Asha
Aanganwadi Worker
local newspaper-regional
National newspaper
Radio
Television
Political / Religious Community leaders
officials/bdo/medical officer
panchayat members/member of health committee (nrhm)
Other
B03
What according to you are the services they offer?
Family planning
Immunization
Antenatal Care/check-up
Delivery/delivery care
Postnatal care
Disease prevention
Medical treatment for self (basic illness-diarrhoea, pneumonia, TB, Kala Azar OR /minor injury)
Medical treatment for self (long term illness/major injury)
Medical treatment for child (basic illness-diarrhoea, pneumonia, TB, Kala Azar OR minor injury)
Medical treatment for child (long term illness/major injury)
Medical treatment for other person (basic illness-diarrhoea, pneumonia, TB, Kala Azar OR minor injury)
Medical treatment for other person (long term illness/major injury)
Growth monitoring of child
Health check-up
Others (specify)
B04
Are you interested in using their services?
Yes
No
B05
(If No) Why not?
distance to facility
too expensive
time consuming to wait
lack of available facilities
mistrust of their health services provision
Belief system
No drugs available
other (specify)
B06
Have you ever sought any advice/ treatment for any illness from there?
Yes
No
B07
(If answered yes in A06) for what service did you visit the facility?
Family planning
Immunization
Antenatal Care/check-up
Delivery/delivery care
Postnatal care
Disease prevention
Medical treatment for self (basic illness-diarrhoea, pneumonia, TB, Kala Azar OR /minor injury)
Medical treatment for self (long term illness/major injury)
Medical treatment for child (basic illness-diarrhoea, pneumonia, TB, Kala Azar OR minor injury)
Medical treatment for child (long term illness/major injury)
Medical treatment for other person (basic illness-diarrhoea, pneumonia, TB, Kala Azar OR minor injury)
Medical treatment for other person (long term illness/major injury)
Growth monitoring of child
Health check-up
Others (specify)
B08
Do you know anyone who has sought advice / treatment for any illness from there?
Yes
No
DIarhhoea (FOR child EXACTLY 5 YEARS OF AGE OR BELOW )
C01
In the last two weeks, has (name) had diarrhoea (loose watery stools)?
Yes
No
C02
During this episode of illness did (name) have any of the following symptoms?
C02_1
blood in the stool
Yes
No
C02_2
FEVER
Yes
No
C02_3
persistent vomiting
Yes
No
C02_4
sunken eyes
Yes
No
C02_5
the child become lethargic
Yes
No
C03
How many days ago did the first of these symptoms begin?
C04
Are the symptoms still present?
Yes
No
C05
If no, how many days did the symptoms last?
C06
During the time (name) had diarrhoea, did the child feel more thirsty than usual?
Less
About the same
More
DK
C07
During the time (name) had diarrhoea, was he/she given less than usual to drink, about the same amount, or more than usual?
Less
About the same
More
Nothing to drink
DK
C08
During the time (name) had diarrhoea, did the child feel more hungry than usual?
Less
About the same
More
DK
C09
During the time (name) had diarrhoea, was he/she given less than usual to eat, about the same amount, more than usual, or
Less
About the same
More
Stopped food
Never gave food
DK
C10
Did you seek any advice/treatment for diarrhoea from any source for the child
Yes
No
C11
if No, please specify the reason for not seeking treatment for diarrhoea
Could not get away from work
Did not have money
There is no doctor/health facility nearby
Was not serious
Don’t know
Others (Specify)
C12
Please give me the names of the persons from whom you sought advice or the providers you visited for treatment, starting with the first person or provider you visited.
C13
Is this person a medical provider?
Yes
No
C14
Was this person ever a medical provider?
Yes
No
C15
please specify the relationship of the persons whom you asked for advice on the child’s illness
Wife / Husband
Other relative
Non-relatives/friends/neighbours
Others (specify)
C16
What was the advice given?
Fluid from ORS packet
Pre-packaged ORS Gruel
Homemade ORS fluid
Zinc Tablet
Zinc syrup
Pill or Syrup Antibiotic
Non-antibiotic syrup
Antimotility
Home remedy, Herbal medicine
IV line
Pills crushed to powder and wrapped in paper
See Medical Provider
Nothing
Others (specify)
C17
Did you follow this advice?
Yes
No
C18
Did the symptoms improve?
Yes
No
C19
How much did you spend on this treatment, approximately (Rs.)
C20
Did this person refer you to a medical provider?
Yes
No
C21
Provider Code
provider 1
provider 2
provider 3
provider 4
provider 5
provider 6
provider 7
provider 8
provider 9
C22
What is the category of provider?
Private doctor/hospital outside catchment area
Private doctor/hospital in catchment area
Government doctor/hospital outside catchment area
Government doctor/hospital in catchment area
Service provider like ANM/ASHA/AWW
Pharmacy or Medical store
Doctor in kasba or market
Others (specify)
C23
How long did you have to wait before you received the service you went for?
C24
What Did the care include?
C24A
Medicines Recommended
Fluid from ORS pac ket
Pre-packaged ORS Gruel
Homemade ORS fluid
Zinc Tablet
Zinc syrup
Pill or Syrup Antibiotic
Non-antibiotic syrup
Antimotility
Home remedy, Herbal medicine
IV line
Pills crushed to powder and wrapped in paper
Unknown injection
Nothing
Others (specify)
C24B
Total No. of days each medicine was taken
C24C
No. of times each medicine was taken in a day
C24D
Was the child hospitalized?
Yes
No
C24E
If YES, then for how many days?
C25
Did the symptoms improve?
Child recovered fully
Child improved somewhat
Child did not improve at all or got worse
Child admitted to hospital
child died
C26
Please specify the total no. of visits to the provider
C27
How much time did you spend on travelling (to and from) to the provider?
C28
What was the total cost of the treatment? (Include attendant costs) (In Rs.)
C28A
Consultation, medicines, and tests
C28B
Travel
C28C
Hospitalization Charges including Food, accommodation etc.
C28D
Any Other cost?
C28E
Total Cost
C29
Please rate the level of satisfaction on a scale of 1 to 5 for the treatment by the provider.
C29_1
This provider has all the medicines needed by you
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
C29_2
The doctor gave you complete information about your illness
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
C29_3
Provider staff talk politely
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
C29_4
You are given enough time to tell the doctor everything
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
C29_5
The cleanliness of the facilities is adequate
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
C30
Just to make sure that I have a complete listing, are there any other persons such as friends, neighbors, relatives, pharmacists, doctors or nurses from whom you sought advice for the child’s illness?
Yes
No
C31
did you undertake any self-treatment for diarrhoea of the child?
Yes
No
C32
What was the specific medicine given to the child for diarrhhoea during self-treatment?
C32_1
Fluid from ORS packet
Yes
No
C32_2
Pre-packaged ORS Gruel
Yes
No
C32_3
Homemade ORS fluid
Yes
No
C32_4
Zinc Tablet
Yes
No
C32_5
Zinc syrup
Yes
No
C32_6
Pill or Syrup Antibiotic
Yes
No
C32_7
Non-antibiotic syrup
Yes
No
C32_8
Antimotility
Yes
No
C32_9
Home remedy, Herbal medicine
Yes
No
C32_10
IV Line
Yes
No
C32_11
Injections
Yes
No
C32_12
Other(specify)
Yes
No
C33
How much did you spend on these items approximately?
C34
Did/do you buy any supplements for diet of the child because of the diarrhea, for example vitamins, meat, energy drinks, soft drinks, fruits or medicines?
Yes
No
C35
If YES, What kind of items? (specify all that apply)
Fruits
Drinks
Vitamins/Herbs
Meat
Other (specify)
C36
How much did you spend on these items approximately?
C37
How many days was the child not able to engage in his usual activity due to the illness?
C38
How many of those days would have been spend in school?
C39
How many full days of work did the attendant miss due to the illness?
C40
How many less than full days of work did the attendant miss due to the child’s illness?
C41
What sources of your own or your household money did you rely on to pay for the health related costs, including health care costs, medicine, remedies and supplements?
C41_1
Reduced Savings
Yes
No
C41_2
Reduced Consumption / Regular Monthly Expenditures
Yes
No
C41_3
Children Dropped out from School
Yes
No
C41_4
Sold Jewellery and Household Goods
Yes
No
C41_5
Sold Livestock
Yes
No
C41_6
Reduced or Delayed Investments
Yes
No
C41_7
Mortgaged Assets
Yes
No
C41_8
borrowed money
Yes
No
C41_9
Government programs
Yes
No
C41_10
Private Insurance
Yes
No
C41_11
Gifts from neighbours / friends / relatives
Yes
No
C42
please specify the source of for the borrowing, else go to next section
person-to-person loans
Bank / Commercial Lender
Traditional Money Lender
Employer
Other (specify)
C43
If borrowed money trhough person-to-person loans, please specify the source of for the borrowing.
Wife / Husband
Other relative
Non-relatives/friends/neighbours
Don’t know
Others (specify)
PNEUMONIA (FOR CHILD EXACTLY 5 YEARS OF AGE OR BELOW)
D01
At any time in the last two weeks, has (name) had an illness with a FEVER ?
Yes
No
D02
At any time in the last two weeks, has (name) had an illness with a cough?
Yes
No
D03
Was the condition of the child similar to that seen in this video
Yes
No
D04
please specify why (name) is not similar to the child in the video?
D05
was (name) diagnosed with pneumonia?
Yes
No
D06
When (name) had an illness with a cough, did he/she breathe faster than usual with short, rapid breaths or have difficulty breathing?
Yes
No
D07
Was the fast or difficult breathing due to a problem in the chest or a blocked or runny nose?
Problem in chest only
Blocked or runny nose only
Both
Other (specify)
DK
D08
How many days ago did the fever/cough/rapid breathing start?
D09
Is the child still sick with the fever or cough?
Fever only
Cough Only
Both
No Neither
DK
D10
How many days did the fever and cough last?
D11
During the time (name) had cough and rapid breathing, was he/she given less than usual to drink, about the same amount, or more than usual?
Less
About the same
More
Nothing to drink
DK
D12
During the time (name) had cough and rapid breathing, was he/she given less than usual to eat, about the same amount, more than usual, or nothing to eat?
Less
About the same
More
Stopped food
Never gave food
DK
D13
Did you seek any advice or treatment for the illness from any source?
Yes
No
D14
if No, please specify the reason for not seeking treatment for illness.
Could not get away from work
Did not have money
There is no doctor/health facility nearby
Was not serious
Others (Specify)
D15
how many days after the symptoms began, did you first seek advice/treatment?
D16
Please give me the names of the persons from whom you sought advice and the providers you visited for treatment, starting with the first person or provider you visited.
D17
Was this person a medical provider?
Yes
No
D18
Was this person ever a medical provider?
Yes
No
D19
please specify the relationship of the persons whom you asked for advice on the child’s illness
Wife / Husband
Other relative
Non-relatives/friends/neighbours
Others (specify)
D20
What was the advice given?
Pill or Syrup Antibiotic
Non-antibiotic syrup
WHP Branded antibiotic
injection
Anti-malarials
Paracetamol/Panadol/Acetaminophen
Aspirin
Ibuprofen
Dispersible Tablets
IV Fluid
Nebulizer
Nothing
Others (specify)
DK
D21
Did you follow this advice?
Yes
No
D22
Did the symptoms improve?
Child recovered fully
Child improved somewhat
Child did not improve at all or got worse
Child admitted to hospital
child died
D23
How much did you spend on this treatment, approximately (Rs.)
D24
Did this person recommend you seek medical care?
Yes
No
D25
Provider Code
provider 1
provider 2
provider 3
provider 4
provider 5
provider 6
provider 7
provider 8
provider 9
D26
What is the category of provider?
Private doctor/hospital outside catchment area
Private doctor/hospital in catchment area
Government doctor/hospital outside catchment area
Government doctor/hospital in catchment area
Service provider like ANM/ASHA/AWW
Pharmacy or Medical Store
Doctor at kasba or market
Others (specify)
D27
How long did you have to wait before you received the service you went for?
D28
What Did the care include?
D28_1
Medicines Recommended
Pill or Syrup Antibiotic
Non-antibiotic syrup
WHP Branded antibiotic
injection
Anti-malarials
Paracetamol/Panadol/Acetaminophen
Aspirin
Ibuprofen
Dispersible Tablets
IV Fluid
Nebulizer
Nothing
Others (specify)
DK
D28_2
Did you already have this drug at home?
Yes
No
D28_3
Total No. of days each medicine was taken
D28_4
No. of times each medicine was taken in a day
D28_5
Did the child take the full course of antibiotics?
Yes
No
D28_6
If “no”, why was the antibiotic discontinued?
Child refused the medicine
Child was unable to take fluids by mouth
Child vomited or had abdominal pain
Child developed rash
Parent thought that lesser duration was sufficient
Other
D28_7
Did the care include tests?
Yes
No
D28_8
Was the child hospitalized?
Yes
No
D28_9
If yes, for how many days?
Yes
No
D29
Did the symptoms improve?
Yes
No
D30
What symptoms remain?
Cough
Fever
Fast and difficult breathing
Other
D31
Please specify the total no. of visits to the provider
D32
How much time did you spend on travelling (to and from) to the provider?
D33
What was the total cost of the treatment? (Include attendant costs) (In Rs.)
D33_1
Consultation, medicines, and tests
D33_2
Travel
D33_3
Hospitalization Charges including Food, accommodation etc.
D33_4
Any Other cost?
D33_5
Total Cost
D36
Please rate the level of satisfaction on a scale of 1 to 5 for the treatment by the provider.
D36_1
This provider has all the medicines needed by you
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
D36_2
The doctor gave you complete information about your illness
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
D36_3
Provider staff talk politely
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
D36_4
You are given enough time to tell the doctor everything
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
D36_5
The cleanliness of the facilities is adequate
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
D37
Just to make sure that I have a complete listing, are there any other persons such as friends, neighbors, relatives, pharmacists, doctors or nurses from whom you sought advice for the child’s illness?
Yes
No
D38
Did you undertake any self-treatment for the child?
Yes
No
D39
What was the specific medicine given to the child for diarrhhoea during self-treatment?
D39_1
Pill or Syrup Antibiotic
Yes
No
D39_2
Non-antibiotic syrup
Yes
No
D39_3
WHP Branded antibiotic
Yes
No
D39_4
Anti-malarials p
Yes
No
D39_5
Paracetamol/Panadol/Acetaminophen
Yes
No
D39_6
Aspirin
Yes
No
D39_7
Ibuprofen
Yes
No
D39_8
Home remedy, Herbal medicine
Yes
No
D39_9
IV Line
Yes
No
D39_10
Nebulizer
Yes
No
D39_11
Other(specify)
Yes
No
D40
How much did you spend on these items approximately?
D41
Did/do you buy any supplements for diet because of the illness, for example vitamins, meat, energy drinks, soft drinks, fruits or medicines?
Yes
No
D42
If YES, What kind of items? (specify all that apply)
Fruits
Drinks
Vitamins/Herbs
Meat
Other (specify)
D43
How much did you spend on these items approximately?
D44
How many days was the child not able to engage in his usual activity due to the illness?
D45
How many of those days would have been spent in school?
D46
How many full days of work did the attendant miss due to the illness?
D47
How many less than full days of work did the attendant miss due to the child’s illness?
D50
What sources of your own or your household money did you rely on to pay for the health related costs, including health care costs, medicine, remedies and supplements?
Reduced Savings
Reduced Consumption / Regular Monthly Expenditures
Children Dropped out from School
Sold Jewellery and Household Goods
Sold Livestock
Reduced or Delayed Investments
Mortgaged Assets
borrowed money
Government programs
Private Insurance
Gifts from neighbours / friends / relatives
Other (specify )
D51
If coded 8 i.e. borrowed money, please specify the source of for the borrowing, else go to next section
person-to-person loans
Bank / Commercial Lender
Traditional Money Lender
Employer
Other (specify)
D48
If borrowed money, please specify the source of for the borrowing
Wife / Husband
Other relative
Non-relatives/friends/neighbours
Don’t know
Others (specify)
D49
Pneumonia score questions
D49_1
Has (name) suffered from a cough in the past two weeks?
Yes
No
D49_2
Has (name) suffered from fever over the past two weeks?
Yes
No
D49_3
Has (name) suffered from chills or sweats over the past two weeks?
Yes
No
D49_4
Has (name) been restless over the past two weeks?
Yes
No
D49_5
Has (name) been unusually irritable over the past two weeks? 'bhakatraj_joshi@yahoo.co.in'
Yes
No
D49_6
Has (name) had any loss of appetite over the past two weeks?
Yes
No
D49_7
Has (name) been abnormally sleepy or difficult to wake over the past two weeks?
Yes
No
D49_8
Have you noticed (name) making a wheezing sound when he/she breathed over the last (__) weeks?
Yes
No
D49_9
Has (name) appeared short of breath over the past two weeks?
Yes
No
D49_10
Has there been a period over the past two weeks when (name) has seemed to be breathing faster than normal?
Yes
No
D49_11
Have you noticed (name’s) nostrils flaring when he/she breathed over the past two weeks?
Yes
No
D49_12
Has (name) refused to drink or had a definite decrease in the amount of water he / she drank over the past two weeks?
Yes
No
D49_13
Did you notice that (name’s) skin between their ribs, or his/ her tummy move inwards when they breathed over the past two weeks
Yes
No
D49_14
Did (name) seem to have any chest pain over the past two weeks?
Yes
No
D49_15
Has there been a period over the last two weeks where (name) seemed to have difficulty breathing?
Yes
No
D49_16
Has (name) vomited at all over the past two weeks?
Yes
No
D49_17
Have you heard (name) making grunting noises during the past two weeks?
Yes
No
D49_18
Has (name) appeared to have a slightly blue coloration to his/her skin, particularly their lips or tongue, over the past two weeks
Yes
No
D49_19
Has (name) coughed up any blood over the past two weeks?
Yes
No
D49_20
Has (name) had any fits over the past two weeks
Yes
No
FOR child EXACTLY 5 YEARS OF AGE OR BELOW
E01
Have you ever breastfed (NAME OF CHILD)?
Yes
No
E02
why did you never breastfeed (name of child)
problem with breast (pain, cracked nipples etc)
child did not suck well
not enough time to feed
mother felt there was not enough breastmilk
mother wnted to get pregnant again
No need to breastfeed
infant resisted breastfeeding
other (specify)
E03
How long after birth did you first put (name of child) to the breast?
Immediately or within 1 hour
hours
days
don’t know
E04
was (name of child) given anything other than breast milk within the first day?
Yes
No
E05
what was (name of child) given?
milk from an animal (not breast milk)
plain water
sugar or glucose water
gripe water
sugar-salt-water solution
fruit juice
infant formula/ lactogen
tea
honey
janam ghutti
other (specify)
E06
Are you currently breastfeeding (NAME OF CHILD)?
Yes
No
E07
How old was (NAME OF CHILD) when you stopped giving breastmilk?
E08
Why did you stop breastfeeding (NAME OF CHILD)
problem with breast (pain, cracked nipples etc)
child did not suck well
not enough time to feed
mother felt there was not enough breastmilk
mother wnted to get pregnant again
mother got pregnant / new infant born
mother went back to work
infant resisted breastfeeding
infant already grown up
other (specify)
E09
Have you started giving anything to eat or to drink other than breast milk or formula to (NAME OF CHILD)?
Yes
No
E10
From when/at what age did you first start giving any liquids/semi-solids of solid food (other than breast milk, formula or medicines), to (NAME OF CHILD)?
E11
The last time you fed [CHILDNAME] did you wash your hands before feeding?
Yes
No
E13
Have you ever utilized any services from AWC for your child
Yes
No
E14
How would you rate the child’s overall health in the past 30 days?
Very Bad
Bad
Moderate
Good
Very Good
Self-reported Health
F01
How would you rate your overall health in the past 30 days?
Very bad
Bad
Moderate
Good
Very good
F02
When your child is ill, who makes the final decision to go to the doctor / health facility?
You
Other
You jointly with others
F03
When you are ill, who makes the final decision to go to the doctor / health facility?
You
Other
You jointly with others
F04
The last time you used the toilet, did you wash your hand afterwards?
Yes
No
F05
If yes, what did you use (water only/water and soap/water and surf/ash/soil/other)?
Water only
Water and Soap
Water and surf
Ash
Soil
Other (specify)
F06
On what other occasions did you wash your hands with soap since this time yesterday?
No soap available
Before cooking
After handling food
Before eating
After cleaning infant feces
Soap available in household but did not use it to wash hands
when i wash clothes
when i bathe
when i wash dishes
other (specify)
F07
Is soap available in the household?
Yes
No
F08
Has any health worker, ASHA, AWW or ANM, ever demonstrated proper hand washing using water and soap to you?
Yes
No
Child Immunization
G01
Has [NAME] ever received any vaccinations to prevent him/her from getting diseases?
Yes
No
G02
Can you tell me if (NAME) has ever received the following vaccinations?:
BCG (injection in the left shoulder that causes a scar)
POLIO (vaccination drops for polio)
DPT (injection in the thigh or buttocks againt Tetanus, Whooping cough, Diptheria)
MEASLES (injection in the thigh/arm after 9 months of age)
VIT.A (Vitamin A liquid or capsule for protection against night blindness)
None
G03
Does [NAME] have a vaccination card??
Yes
No
G04
RECORD VACCINATIONS LISTED ON VACCINATION CARD.
BCG (injection in the left shoulder that causes a scar)
POLIO (vaccination drops for polio)
DPT (injection in the thigh or buttocks againt Tetanus, Whooping cough, Diptheria)
MEASLES (injection in the thigh/arm after 9 months of age)
VIT.A (Vitamin A liquid or capsule for protection against night blindness)
None
Health seeking behaviour
I01
In the last15 days, Did any member of the household have any episodes of illness or sought preventive care apart from the child’s illnesses mentioned previously?
Yes
No
I02
Name of the household member who were ill or sought preventive care in the last month/15 days?
I03
HH ID
I04
Was this individual diagnosed with Tuberculosis
Yes
No
I05
to be asked only for adult patient
I05A
How many full days of work did the patient lost due to the illness?
I05B
How many less than full days of work did the patient lost due to the illness?
I06
ask all
I06A
How many full days of work did the attendant lost due to the illness of the patient?
I06B
How many less than full days of work did the attendant lost due to the illness?
I07
to be asked for child patients
I07A
How many days was the child not able to engage in his usual activity due to illness?
I07B
if applicable, how many days of school did the child miss lost due to illness?
I08
Please give me the names of the persons from whom you sought advice and the providers you visited for treatment, starting with the first person or provider you visited.
I09
Is this person a medical provider?
Yes
No
I10
Was this person ever a medical provider?
Yes
No
I11
please specify the relationship of the persons whom you asked for advice on the illness
Wife / Husband
Other relative
Non-relatives/friends/neighbours
Others (specify)
I12
How much did you spend on this treatment, approximately (Rs.)
I13
Did this person recommend you seek medical care?
Yes
No
I14
Please specify the total no. of visits to the provider
I15
How much time did you spend on travelling (to and from) to the provider?
I16
What was the total cost of the treatment? (Include attendant costs) (In Rs.)
I16_1
Consultation, medicines, and tests
I16_2
Travel
I16_3
Hospitalization Charges including Food, accommodation etc.
I16_4
Any Other cost?
I16_5
Total Cost
I17
Please rate the level of satisfaction on a scale of 1 to 5 for the treatment by the provider.
I17_1
This provider has all the medicines needed by you
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I17_2
The doctor gave you complete information about your illness
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I17_3
Provider staff talk politely
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I17_4
You are given enough time to tell the doctor everything
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I17_5
The cleanliness of the facilities is adequate
Strongly disagree
Disagree
Neutral
Agree
Strongly agree
I18
Just to make sure that I have a complete listing, are there any other persons such as friends, neighbors, relatives, pharmacists, doctors or nurses from whom you sought advice for the illness?
Yes
No
I19
Did you undertake any self-treatment for the child?
Yes
No
I20
How much did you spend on these items approximately?
I21
Did/do you buy any supplements for diet because of the illness, for example vitamins, meat, energy drinks, soft drinks, fruits or medicines?
Yes
No
I22
If YES, What kind of items? (specify all that apply)
Fruits
Drinks
Vitamins/Herbs
Meat
Other (specify)
I23
How much did you spend on these items approximately?
I24
What was the reason for NOT seeking Care
Could not get away from work
Did not have money
There is no doctor/health facility nearby
Was not serious
DK
Others (Specify)
I25
What sources of your own or your household money did you rely on to pay for the health related costs?
I25_1
Reduced Savings
Yes
No
I25_2
Reduced Consumption / Regular Monthly Expenditures
Yes
No
I25_3
Children Dropped out from School
Yes
No
I25_4
Sold Jewellery and Household Goods
Yes
No
I25_5
Sold Livestock
Yes
No
I25_6
Reduced or Delayed Investments
Yes
No
I25_7
Mortgaged Assets
Yes
No
I25_8
borrowed money
Yes
No
I25_9
Government programs
Yes
No
I25_10
Private Insurance
Yes
No
I25_11
Gifts from neighbours / friends / relatives
Yes
No
I25_12
Other (specify )
Yes
No
I26
If coded 8 i.e. borrowed money, please specify the source of for the borrowing, else go to next section
person-to-person loans
Bank / Commercial Lender
Traditional Money Lender
Employer
Other (specify)
I27
If borrowed money, please specify the source of for the borrowing
Wife / Husband
Other relative
Non-relatives/friends/neighbours
Don’t know
CONSUMPTION AND INCOME
J01
In the past 7 days how much did the household consume the following items?
J01_1
Rice
J01_2
Wheat
J01_3
Other Cereals
J01_4
Pulses and pulse products (includes soyabean, gram)
J01_5
Meat, Chicken and Fish
J01_6
Edible Oil and vanaspati
J01_7
Milk and Milk products like ghee, butter, ice cream,milk powder, dahi, paneer, etc.
J01_8
Vegetables (including garlic, ginger)
J01_9
Any other (specify)
J02
Whether consumed?
J02_1
Rice
Yes
No
J02_2
Wheat
Yes
No
J02_3
Other Cereals
Yes
No
J02_4
Pulses and pulse products (includes soyabean, gram)
Yes
No
J02_5
Meat, Chicken and Fish
Yes
No
J02_6
Edible Oil and vanaspati
Yes
No
J02_7
Milk and Milk products like ghee, butter, ice cream,milk powder, dahi, paneer, etc.
Yes
No
J02_8
Vegetables (including garlic, ginger)
Yes
No
J02_9
Any other (specify)
Yes
No
J03
How much (kgs)?
J03_1
Rice
J03_2
Wheat
J03_3
Other Cereals
J03_4
Pulses and pulse products (includes soyabean, gram)
J03_5
Meat, Chicken and Fish
J03_6
Edible Oil and vanaspati
J03_7
Milk and Milk products like ghee, butter, ice cream,milk powder, dahi, paneer, etc.
J03_8
Vegetables (including garlic, ginger)
J03_9
Any other (specify)
J04
Was this
J04_1
Rice
home grown
purchased
received in-kind?
J04_2
Wheat
home grown
purchased
received in-kind?
J04_3
Other Cereals
home grown
purchased
received in-kind?
J04_4
Pulses and pulse products (includes soyabean, gram)
home grown
purchased
received in-kind?
J04_5
Meat, Chicken and Fish
home grown
purchased
received in-kind?
J04_6
Edible Oil and vanaspati
home grown
purchased
received in-kind?
J04_7
Milk and Milk products like ghee, butter, ice cream,milk powder, dahi, paneer, etc.
home grown
purchased
received in-kind?
J04_8
Vegetables (including garlic, ginger)
home grown
purchased
received in-kind?
J04_9
Any other (specify)
home grown
purchased
received in-kind?
J05
How much did you pay for the food item consumed in past 7 days?
J05_1
Rice
J05_2
Wheat
J05_3
Other Cereals
J05_4
Pulses and pulse products (includes soyabean, gram)
J05_5
Meat, Chicken and Fish
J05_6
Edible Oil and vanaspati
J05_7
Milk and Milk products like ghee, butter, ice cream,milk powder, dahi, paneer, etc.
J05_8
Vegetables (including garlic, ginger)
J05_9
Any other (specify)
J06
How much would have cost you to purchase the food item consumed in past 7 days?
J06_1
Rice
J06_2
Wheat
J06_3
Other Cereals
J06_4
Pulses and pulse products (includes soyabean, gram)
J06_5
Meat, Chicken and Fish
J06_6
Edible Oil and vanaspati
J06_7
Milk and Milk products like ghee, butter, ice cream,milk powder, dahi, paneer, etc.
J06_8
Vegetables (including garlic, ginger)
J06_9
Any other (specify)
J07
Over the past 30 days what was the total value of the following items that the household consumed?
J07_1
Paan
J07_2
Tobacco
J07_3
Alcohol
J08
In the past 30 days, how much did you consume (in Rs.) of the following items? (includes purchased and received in-kind)
J08_1
Food at restaurants (eating out)
J08_2
Fuel and light (LPG, electricity, firewood) Exclude kerosene
J08_3
Entertainment (includes cinema, picnic, sports, club fees,video cassettes.)
J08_4
Telephone
J08_5
Cable & internet
J08_6
Personal care (includes spectacles, torch, umbrella, lighter, etc.)
J08_7
Toilet articles (includes toothpaste, hair oil, shaving blades, etc.
J08_8
Household items (includes electric bulb, tubelight, glassware, bucket, washing soap, agarbati, insecticide, etc.)
J08_9
Conveyance (includes railway, bus, taxi, rickshaw, air fares, porter charges, diesel, petrol, school, bus/van, etc.)
J08_10
House rent, rent (also for rented household appliances, furniture, etc)
J08_11
Services (domestic servants, other)
J09
In the past 12 months, how much did you consume (in Rs.) of the following items? (includes purchased and received in-kind)
J09_1
School / Private Tuition fees (includes private tutor, school /college fees)
J09_2
School books & other educational articles (includes newspaper, library charges,stationery, internet charges)
J09_3
Clothing and bedding
J09_4
Furniture and fixtures (includes bedstead, almirah, suitcase, carpet, paintings, etc.)
J09_5
Crockery and utensils (includes stainless steel utensils,casseroles, thermos, etc.)
J09_6
Cooking and Household Appliances (includes electric fan, AC, sewing machine,washing machine, pressure cooker, refrig.
J09_7
Goods for Recreation (includes TV, radio, Tape recorder,musical instruments)
J09_8
Jewelry and ornaments
J09_9
Personal transport equipment includes bicycle, scooter, car, tyres, etc.)
J09_10
Therapeutic appliances includes glass eye, hearing aids, orthopaedic equipment, etc.)
J09_11
Other personal goods includes clock, watch, PC, telephone, mobile, toys etc.)
J09_12
Social functions: (marriage, funerals, gifts, etc.)
J09_13
Religious expenses
J10
Do you receive any remittances from any of the household members?
Yes
No
J11
If yes, then what is the amount of remittances received in the last 12 months?
J12
Is this household member engaged in paid labor?
Yes
No
J13
Primary source of income
Agriculture
Petty Trader
Skilled Worker
Local Labour
Migrant Labor
Salaried OSRU
Others (If Any)
J14
Annual Revenue
J15
Expense/ Cost
J16
Secondary source of income
Agriculture
Petty Trader
Skilled Worker
Local Labour
Migrant Labor
Salaried OSRU
Others (If Any)
J17
Annual Revenue
J18
Expense/ Cost
Household Assets
K01
Does your household own this house or any other house?
Yes
No
K02
What is the type of your house
Pucca
Semi Pucca
Kuccha
K03
What is the main source of drinking water for members of your household?
Piped water in residence/yard/plot
Hand pump in residence/yard/plot
Well water in residence/yard/plot
Public hand pump
Public tap
Public well
Bore well
Canal
Other source (specify)
K04
What kind of toilet facility does your household have?
Open Defection
Flush to piped sewer system
Flush to septic tank
Flush to pit latrine
Flush to somewhere else
Ventilated improved pit biogas latrine
Pit latrine with slab
Pit latrine without slab/ open pit
Twin pit/composting toilet
Dry toilet
Others (specify)
K05
What is the main source of lighting for your household?
Electricity
Kerosene lamp
Gas lamp
Candle
Solar energy
Other (specify)
K06
What type of fuel does your household commonly use for cooking?
Wood
Crop residues
Dung cakes
Coal/ charcoal
Kerosene
Electricity
Liquid petroleum gas
Bio-gas
Other (specify)
K07
What is the main material of which the floor is made of?
Natural roof (no wall/thatch/grass/mud/cane /bamboo)
Rudimentary roof (Mat/Bamboo/Unburnt Brick/raw wooden planks/stones)
Finished roof (Metal/cement/wood/asbestos sheets/tiles/concrete/burnt bricks)
K08
What is the main material of which the roof is made of?
Natural roof (no wall/thatch/grass/mud/cane /bamboo)
Rudimentary roof (Mat/Bamboo/Unburnt Brick/raw wooden planks/stones)
Finished roof (Metal/cement/wood/asbestos sheets/tiles/concrete/burnt bricks)
K09
What is the main material of which the exterior walls are made of?
Natural roof (no wall/thatch/grass/mud/cane /bamboo)
Rudimentary roof (Mat/Bamboo/Unburnt Brick/raw wooden planks/stones)
Finished roof (Metal/cement/wood/asbestos sheets/tiles/concrete/burnt bricks)
K10
What is the type of windows in the house?
Window with screens
Window with glass
Window with shutters or curtains
Any other window
None
K11
How many rooms in this house are used for sleeping?
K12
Does your household own any of the following items:
K12_1
Electric connection
Yes
No
K12_2
Pressure cooker
Yes
No
K12_3
Mixer/grinder
Yes
No
K12_4
Motorcycle/scooter
Yes
No
K12_5
Car/Jeep
Yes
No
K12_6
Tractor
Yes
No
K12_7
Bicycle
Yes
No
K12_8
Animal-drawn cart
Yes
No
K12_9
Chair
Yes
No
K12_10
Table
Yes
No
K12_11
Cot/ Bed
Yes
No
K12_12
Mattress
Yes
No
K12_13
Clock or watch
Yes
No
K12_14
Electric fan
Yes
No
K12_15
Water pump
Yes
No
K12_16
Thresher
Yes
No
K12_17
Radio/Transistor
Yes
No
K12_18
Sewing machine
Yes
No
K12_19
Refrigerator
Yes
No
K12_20
B & W television
Yes
No
K12_21
Colour television
Yes
No
K12_22
Telephone
Yes
No
K12_23
Computer
Yes
No
K12_24
Cell Phone
Yes
No
K13
Does your household have a bank account or post-office account?
Yes, bank account
Yes, post office account
Both
None
K14
Does your household own livestock?
Yes
No
K15
Vegetables (including garlic, ginger)
K15_1
Bullocks
Yes
No
K15_2
Buffalo/ Cow/ Cross bred cow
Yes
No
K15_3
Goats/Lambs
Yes
No
K16
Does this household have any agricultural land?
Yes
No
K17
How much agricultural land does this household own?
K18
Out of this land, how much is irrigated?
Groups, trust and solidarity
L01
How many adults outside of your household did you sepnd leisure time with in the last 7 days?
L02
Of these, how many are relatives?
L03
Of these, how many are friends?
L04
How many people outside of your household would you lend money to if they had a health emergency?
L05
How many people outside of your household could you borrow money from if you had a health emergency?
L06
Generally speaking, would you say that most people can be trusted or that you need to be careful in dealing with people?
Most people can be trusted
You need to be careful when dealing with people
L07
If you were told that “Most people in this village/neighborhood are willing to help if you need it”, would you
Agree totally
Agree to a large extent
Agree to a certain extent
Disagree
Totally disagree
L08
If you were told that “In this village/neighbourhood, one has to be alert or someone is likely to take advantage of you”, would you
Agree totally
Agree to a large extent
Agree to a certain extent
Disagree
Totally disagree
L09
Do you feel that you belong to a group that is discriminated?
Yes
No
L10
How much do you trust the following
L10_1
Anganwadi Workers
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_2
ANM Workers
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_3
ASHA Workers
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_4
Panchayati Raj ZP Officials - Village
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_5
Panchayati Raj ZP Officials - Taluk
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_6
Panchayati Raj ZP Officials - District
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_7
State Government Officials
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L10_8
Central Government Officials
to a very great extent
to a great extent
Neither great nor small extent
To a small extent
To a very small extent
L11
If a community project does not directly benefit you but has benefits for many others in the village/neighbourhood, would you contribute time and / or money to the project
Will contribute
Will not contribute
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