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Household Template 56 -Form Fill
Village Information
Q01
District Name
Q02
District Code
Q03
Block Name
Q04
Block Code
Q05
Village Name
Q06
Village Code
Q07
SSU area name
Q08
SSU area code
Q09
Structure no.
Q10
HH no.
Q11
Unique reference ID
Q12
Total eligible respondents in the household
Q13
Geographical coordinates
Survey Information
A01
Name of the respondent
A02
First Visit
A02_1
Interviewer name
A02_2
Interviewer code
A02_3
Date of the interview
A02_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
REFUSED
A03
Second Visit
A03_1
Interviewer name
A03_2
Interviewer code
A03_3
Date of the interview
A03_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
REFUSED
A04
Third Visit
A04_1
Interviewer name
A04_2
Interviewer code
A04_3
Date of the interview
A04_4
Result of the interview
INTERVIEW COMPLETED
VISIT RESCHEDULED
INTERVIEW INCOMPLETE
HOUSEHOLD NOT LOCATED
RESPONDENT IS OUT OF STATION FOR EXTENDED PERIOD
RESPONDENT IS TEMPORARILY AWAY
OTHER (SPECIFY)
REFUSED
A05
RECORD TIME WHEN YOU START THE INTERVIEW.
Particulars of Household Members
B01
Name
B02
Relationship with the household head
Self
Husband/wife
Father/mother
Son/daughter
Father-in-law/mother-in-law
Brother/sister
Son-in-law/daughter-in-law
Grandson/granddaughter
Uncle/aunt
Grandfather/grandmother
Others (specify)
B03
Gender
Male
Female
Others (specify)
B04
Age-in integers
B05
Marital status
Married
Single
Divorced
Separated
Destitute
Others (please specify)
B06
In the past 365 days / 12 months
B06A
Whether pregnant?
Yes
No
B06B
Outcome of pregnancy
Live birth
Stillbirth
Abortion
Miscarriage
Currently pregnant
B07
Whether suffering from any chronic ailments (health conditions )?
Yes
No
B08
What chronic ailment is this?
Low blood pressure
High blood pressure
Diabetes
Kidney disease
Heart disease
Stroke
Liver disease
Cancer
Mental health (anxiety, depression, etc)
Paralysis
Tuberculosis
Others (specify)
B09
Is the person covered by health insurance?
Yes
No
B10
Type of insurance
Government-sponsored
Employer-sponsored
Arranged by household with insurance company
Pradhan Mantri Jan Arogya Yojana
Others (specify)
B11
Type of ration card
Antyodaya Anna Yojana (AAY) Card Holder
Below Poverty Line card holder
Do not have ration card
Gross Household Expenditure
C01
Household monthly consumption expenditure
C02
Weekly Food cost (Rice, Atta/wheat flour, Fish, Meat, Egg, Milk, Pulses, Vegetable, Fruit, Salt, Sugar, etc.)
C03
Monthly food cost (Spices, Edible oil, others)
C04
Monthly cost for housing; house rent, Imputed rent (if own house), electricity bill, gas bill, water/sanitation bill, garbage disposal bill)
C05
Monthly costs for entertainment (watching cinema, entertaining relatives, etc.)
C06
Monthly out of pocket expenditure on health
C07
Annual costs for clothing
C08
Annual costs for education
Child Health
D01
Age of the child
D02
Gender
Male
Female
Others (specify)
D03
Member code
D04
Does this child go to school ?
Yes
No
D05
In the last two weeks, did the child have diarrhoea (loose watery stools)?
Yes
No
D06
Was there any blood in the child’s stools?
Yes
No
D07
Did you seek any advice/treatment for diarrhoea when the child had diarrhoea the last time?
Yes
No
D08
Where did you seek advice/treatment from first, when the child had diarrhoea the last time?
D09
Type of provider
Medical College
District Hospital
Sub-District Hospital
Community Health Centre - FRU
CHC non-FRU
Primary Health Centre
Urban Primary Health Centre (U-PHC)
Health and Wellness Centres
Sub Centre
Private hospital (with IPD)
Private clinic (only OPD)
Private Diagnostic Centre
NGO/Charitable Hospital
Pharmacy
Qualified Doctor’s Clinic – Homeopath
Qualified Doctor’s Clinic – Siddha/Unani/Ayurveda
Physiotherapy Centre
Care Centre – NGO
Satellite Clinic
Counselling Centre
Tele-consultation (eSanjeevaniOPD)
Mobile Health Units
Village Health and Nutrition Day camp
Anganwadi Centre
Traditional healer
Others
D10
How far did you travel to this provider for getting the child treated for diarrhoea?
D11
What mode of transport did you use while going to the provider?
Ambulance
Private (own) vehicle
Taxi/jeep
Tractor
Two-wheeler
Auto rickshaw/tempo
Other
D12
Why did you choose this provider ?
Good experience with previous illness/care
This was my only choice
I trust this provider
Provider well behaved
Quality of service is good/popular provider
Low-cost services/affordable
Treatment/services available on credit
Service available in the convenient timing
Close to home
Healthcare provider known to me
Advised by friends/family/neighbour
Clean facility
‘One-stop’ (all services in one place)
Telehealth services available
Do not know of any other source
Others
D13
Has the child been ill with a fever at any time in the last 2 weeks?
Yes
No
D14
Has the child been ill with a cough or other breathing difficulty at any time in the last 2 weeks?
Yes
No
D15
When the child had an illness, did he/she breathe faster than usual with short, rapid breaths, have difficulty breathing or chest in drawings?
Yes
No
D16
When the child had this illness, did he/she have a problem in the chest or a blocked or running nose?
Yes
No
D17
Did you seek any advice/treatment for this illness when the child had the illness the last time?
Yes
No
D18
Where did you seek advice/treatment from first, when the child had this illness the last time?
D19
Type of provider
Medical College
District Hospital
Sub-District Hospital
Community Health Centre - FRU
CHC non-FRU
Primary Health Centre
Urban Primary Health Centre (U-PHC)
Health and Wellness Centres
Sub Centre
Private hospital (with IPD)
Private clinic (only OPD)
Private Diagnostic Centre
NGO/Charitable Hospital
Pharmacy
Qualified Doctor’s Clinic – Homeopath
Qualified Doctor’s Clinic – Siddha/Unani/Ayurveda
Physiotherapy Centre
Care Centre – NGO
Satellite Clinic
Counselling Centre
Tele-consultation (eSanjeevaniOPD)
Mobile Health Units
Village Health and Nutrition Day camp
Anganwadi Centre
Traditional healer
Others
D20
How far did you travel to this provider for getting the child treated for pneumonia?
D21
What mode of transport did you use while going to the provider?
Ambulance
Private (own) vehicle
Taxi/jeep
Tractor
Two-wheeler
Auto rickshaw/tempo
Other
D22
Why did you choose this provider ?
Good experience with previous illness/care
This was my only choice
I trust this provider
Provider well behaved
Quality of service is good/popular provider
Low-cost services/affordable
Treatment/services available on credit
Service available in the evening
Close to home
Healthcare provider known to me
Advised by friends/family/neighbour
Clean facility
‘One-stop’ (all services in one place)
Telehealth services available
Do not know of any other source
Others
Geriatric Health
E01
Age of the elderly person
E02
Gender of the elderly person
Male
Female
Others (specify)
E03
Member code
E04
State of economic independence
Not dependent on others
Partially dependent on others
Fully dependent on others
E05
IF NOT DEPENDENT ON OTHERS, number of persons dependent upon the aged person
E06
IF DEPENDENT ON OTHERS, person financially supporting aged person
Spouse
Own children
Grandchildren
Others
E07
Who makes healthcare decisions for the aged person?
Self
Spouse
Own children
Grandchildren
Others
E08
Physical mobility
Confined to Bed
Confined to Home
Able to move outside but with assistive devices (wheelchair, crutches, etc.)
Walking 1 km
Going to toilet without help
Dressing without help
Hearing normal conversation
Speaking normally
Seeing distant things ( with glasses, if any)
Seeing near objects such as reading/ sewing? ( with glasses, if any )
E09
person supporting mobility
Household member
Non-household member
None
E10
Did the aged person seek treatment for these chronic ailments ?
Yes
No
E11
When was the last time the aged person visited a provider for treatment of the chronic ailments?
E12
How often does the aged person visit the provider for treatment of the chronic ailments?
At least once every fortnight
At least once a month
At least once every three months
At least once every six months
At least once every year
E13
Where did the aged person seek treatment for these ailments?
E14
Type of provider
Medical College
District Hospital
Sub-District Hospital
Community Health Centre - FRU
CHC non-FRU
Primary Health Centre
Urban Primary Health Centre (U-PHC)
Health and Wellness Centres
Sub Centre
Private hospital (with IPD)
Private clinic (only OPD)
Private Diagnostic Centre
NGO/Charitable Hospital
Pharmacy
Qualified Doctor’s Clinic – Homeopath
Qualified Doctor’s Clinic – Siddha/Unani/Ayurveda
Physiotherapy Centre
Care Centre – NGO
Satellite Clinic
Counselling Centre
Tele-consultation (eSanjeevaniOPD)
Mobile Health Units
Village Health and Nutrition Day camp
Anganwadi Centre
Traditional healer
Others
E15
How long does it take for the aged person travel to this provider?
E16
What mode of transport does he/she/they use while going to the provider?
Ambulance
Private (own) vehicle
Taxi/jeep
Tractor
Two-wheeler
Auto rickshaw/tempo
Other
E17
Why did the aged person not seek treatment for the chronic ailment?
Total cost of visiting provider (incl. transport, time)
Did not consider ailment serious to warrant treatment
Restrictions in mobility
Long travel distance
Long waiting time
Poor waiting facility
Physician consultation time was less than expected
3rd party influence (Agents) to receive diagnostic care
Service disruption due to COVID-19
Others
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