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Household Template 3 -Form Fill
IDENTIFICATION
Q01
District
Prakasam
Sreekakulam
Nellore
West Godavari
Q02
Mandal
Q03
Village
Q04
Selected HH Structure
Q05
Selected HH Number
Q06
Name of the respondent
Q07
Name of interviewer
Q08
Date of interview
Q09
Time of interview
Q10
Field supervisor
Q11
Back checked by
Q12
Result of the interview
Interview completed and salt sample collected
Interview not completed and salt sample not collected
Q12A
Visit 1
Interview completed and salt sample collected
Interview not completed and salt sample not collected
Q12B
Visit 2
Interview completed and salt sample collected
Interview not completed and salt sample not collected
Q12C
Visit 3
Interview completed and salt sample collected
Interview not completed and salt sample not collected
Q13
DATE
HOUSEHOLD COMPOSITION
A01
Please tell me the names of all 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 household?
Head of Household
Spouse (Wife or Husband)
Son or Daughter
Son-in-law or Daughter-in-law
Grand child
Parent
Parent-in-law
Brother or Sister
Brother-in-law or Sister-in-law
Other Relative
Adopted / Foster Child
Not related
A03
What is the sex of [NAME]?
Male
Female
Transgender
A04
How old is [NAME]?
A05
Caste of the head of household?
Scheduled caste
Scheduled tribe
Other backward caste
General
Other (specify)
Don’t know
A06
Religion of the head of the Household?
Hindu
Muslim
Christian
Sikh
Buddhist/Neo-Buddhist
Jain
Jewish
Parsi/Zoroastrian
No religion
Other (specify)
Don’t know
A07
Is the household a nuclear family or an extended family?
Nuclear Family
Extended Family
A08
Do you know how to read and write?
Yes read
Yes write
Yes read and write
Neither read nor write
A09
Have you ever attended school?
Yes
No
A10
What is the highest standard or class you completed?
Primary
Secondary
Higher Secondary
Graduate
Post graduate
Professional Degree
Others (specify)
A11
What is your primary occupation?
Farmer (crops)
Agricultural day labor
Herding animals
Non-agricultural day labor
Household servant
Cook
Service/salaried worker
Small/cottage industry
Petty business/shop
Business/trader
Other self-employment
Skilled worker
Housewife
Other (specify)
THE HOUSE & HOUSEHOLD ASSETS
B01
Does your household own a house (this house or any other house)?
Yes
No
Don’t Know
B02
What is the type of floor?
Kutcha
Semi-Pucca
Pucca
B03
What is the type of wall?
Kutcha
Semi-Pucca
Pucca
B04
What is the type of roof?
Kutcha
Semi-Pucca
Pucca
B05
How many rooms do you have in your house?
B06
Do you have a separate room which is used as a kitchen?
Yes
No
B07
Does the household have electricity?
Yes
No
B08
How many hours a day do you get electricity in your house?
B09
What type of fuel does your household mainly use for cooking?
Electricity
LPG/Natural Gas
Biogas
Kerosene
Coal/Lignite
Charcoal
Wood
Straw/Shrubs/Grass
Agricultural Crop Waste
Dung Cakes
Other (Specify)
B10
What is the main source of drinking water for members of your household?
Piped into dwelling
Piped to yard/plot
Public tap/standpipe
Tube well/borehole
Protected well
Unprotected well
Protected spring
Unprotected spring
Rainwater
Tanker truck
Cart with small tank
Surface water (River/Dam/Lake/Pond/ Stream/Canal/Irrigation Channel)
Bottled water
Hand pump
Hand pump at Home
Neighbour’s hand pump
Other (Specify)
B11
Do you treat your water in any way to make it safer to drink?
Yes
No
Don’t Know
B12
What kind of toilet facility do members of your household usually use?
Flush to piped sewer system
Flush to septic tank
Flush to pit latrine
Flush to somewhere else
Flush, don't know where
Ventilated improved pit (vip)/biogas latrine
Pit latrine with slab
Pit latrine without slab/ open pit
Twin pit/composting toilet
Dry toilet
No facility/uses open space or field
Other (specify)
B13
Does your household own any of the following
Yes
No
B13_1
A mattress
Yes
No
B13_2
A pressure cooker
Yes
No
B13_3
A chair
Yes
No
B13_4
A cot or bed
Yes
No
B13_5
A table
Yes
No
B13_6
An electric fan
Yes
No
B13_7
A radio or transistor
Yes
No
B13_8
A black and white television
Yes
No
B13_9
A colour television
Yes
No
B13_10
A land phone
Yes
No
B13_11
A sewing machine
Yes
No
B13_12
A mobile telephone with radio
Yes
No
B13_13
A mobile telephone without radio
Yes
No
B13_14
Any other type of telephone
Yes
No
B13_15
A computer/laptop
Yes
No
B13_16
A refrigerator
Yes
No
B13_17
A watch or clock
Yes
No
B13_18
A bicycle
Yes
No
B13_19
A motorcycle or scooter
Yes
No
B13_20
An animal-drawn cart
Yes
No
B13_21
A car/jeep
Yes
No
B13_22
A water pump
Yes
No
B13_23
A thresher
Yes
No
B13_24
A tractor
Yes
No
B13_25
Internet
Yes
No
B13_26
Air Conditioner or Cooler
Yes
No
B13_27
Washing Machine
Yes
No
B14
Which ration card does your household possess?
APL
BPL
AAY
Annapurna
No ration card
Don’t Know
B15
Does any member of your household have Bank Account?
Yes
No
B16
Does any member of your household have Post Office Account?
Yes
No
Consumption and Source of Salt in households
C01
Name of the Lady respondent/ HH member responsible for the kitchen
C02
Do you buy salt for your household?
Yes
No
C03
What determines what kind of salt you buy?
Saltiness
Texture
Colour
Price
Brand
Tradition
Others (specify)______________
C04
Do you buy salt separately for preparing pickles including condiments?
Yes
No
C05
Why do you use separate salt for preparing pickles including condiments?
Saltiness
Texture
Colour
Price
Brand
Tradition
Others (specify)______________
C06
Do you buy table salt separately?
Yes
No
C07
Why do you use separate salt as table salt?
Saltiness
Texture
Colour
Price
Brand
Tradition
Others (specify)______________
C08
Have you ever heard of iodized salt
Yes
No
C09
What kind of salt did you traditionally use for cooking purposes?
Iodised
Non-Iodised
Salt declared as “for preservative purpose”
Don’t know
C10
What kind of salt did you traditionally use for preparation of pickle and other condiment?
Iodised
Non-Iodised
Salt declared as “for preservative purpose”
Don’t know
C11
What kind of salt did you use for your last meal?
Packaged crushed salt
Packaged crystal salt
Loose crystal
Iodised
Non-Iodised
Salt declared as “for preservative purpose”
Don’t know
C12
What kind of salt did you use last time for preparing pickle and other condiments?
Packaged crushed salt
Packaged crystal salt
Loose crystal
Iodised
Non-Iodised
Salt declared as “for preservative purpose”
Don’t know
C13
Why do you buy iodised salt?
I know that it is healthy
Because other kinds of salt are not available
Because doctor Advised
Because the ANM/ ASHA/ AWW Advised
The shopkeeper asked me to buy iodised salt
Household members asked me to buy iodised salt
Friends asked me to buy iodized salt
Panchayat member asked me to buy
Teacher told our children to buy
Others (Specify)……………
C14
Why don’t you buy iodised salt?
I don’t know why is it necessary
It is more expensive
Members of family do not advise to do otherwise
Friends do not advise me to do otherwise
Shopkeepers do not advise me to do otherwise
Others (Specify)……………………………
C15
How do you know that the salt is iodized?
Smiling sun logo
Name of the brand
Word “iodised”
Shopkeeper tells me so
Others (Specify)………………
Don’t Know
C16
Where did you buy the current salt that you use for cooking?
Local kirana/grocery store
Bazaar/ Weekly market
Vendor/salesman
PDS
Others (Specify)
C17
Where do you buy the current salt that you use for pickling and other condiments?
Local kirana/grocery store
Bazaar/ Weekly market
Vendor/salesman
PDS
Others (Specify)_________
C18
In most cases, which member of the household decides where to buy the salt?
Head of the household (respondent)
Spouse of the household head (Husband/Wife)
Other Adult family member
Children
Relatives
Friends
Housemaid
Others (Specify)…………………
Don’t know
C19
In most cases, which member of the household buys salt for the household?
Head of the household (respondent)
Spouse of the household head (Husband/Wife)
Other Adult family member
Children
Relatives
Friends
Housemaid
Others (Specify)…………………
Don’t know
C20
What quantity of salt did you buy last time for cooking purpose?
C21
What quantity of salt did you buy last time for pickling including condiments?
C22
How frequently does the household buy salt?
Weekly
Fortnightly (half a month)
Monthly
Others (Specify)……………………………………
Don’t know
C23
When was the last time you bought salt for cooking purposes?
Within a week
Within a fortnight (last 15 days)
Within a month
Others (Specify)……………………
Don’t know
C24
When was the last time you bought salt for pickling and other condiments purposes?
Within a week
Within a fortnight (last 15 days)
Within a month
Others (Specify)……………………
Don’t know
C25
What was the price you paid to purchase 1 KG of cooking salt to cook the last meal?
C26
What was the price you paid to purchase 1 KG of salt for pickling and other condiments that you used last time?
C27
Are you ready to pay more, if better quality of cooking salt is made available to you?
Yes
No
C28
How much additional amount you will be willing to pay for 1 Kg of iodized salt?
C29
What do you see as the advantages or good things that would happen if you only consume iodized salt (for both pickling and household consumption)?
C30
What do you see as the disadvantages or bad things that would happen if you only consume iodized salt?
C31
What makes it difficult or impossible for you to only consume iodized salt?
C32
What makes it easier for you to only consume iodized salt?
C33
Who (what groups or individuals) do you think would object or disapprove if you only consume iodized salt?
C34
Who (what groups or individuals) do you think would approve or support you if you only consume iodized salt?
C35
Imagine someone who only consumes iodized salt. How would you describe that person? What are they like? That is, what do you see as the characteristics or qualities of a person who only consumes iodized salt?
C36
Now imagine someone who never or rarely consumes iodized salt. How would you describe that person? What are they like? That is, what do you see as the characteristics or qualities of a person who never or rarely consumes iodized salt?
C37
Eating iodized salt regularly will help prevent goiter
Very likely
Somewhat likely
Neither likely nor unlikely
Somewhat unlikely
Very unlikely
C38
Preventing goiter is good for health
Very Good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad
C39
Eating iodized salt regularly will help in mental development of my child
Very likely
Somewhat likely
Neither likely nor unlikely
Somewhat unlikely
Very unlikely
C40
Protecting my unborn child is
Very Good
Somewhat good
Neither good nor bad
Somewhat bad
Very bad
Knowledge on consumption of Iodized Salt
D01
Do you know what is the person diagnosed with?
Yes
No
D02
What is this disorder called?
Goiter
Others
Don’t Know
D03
Do you know what Iodine Deficiency Disorders (IDD) are?
Yes
No
D04
Please tell us what are the Iodine Deficiency Disorders (IDD)
Goiter
Cretinism
Complication during birth
Affects child foetus
Affect intelligence level
Maternal ill health
Don’t Know
Any other (please specify) ____________________
D05
Do you know which food/vegetable items are rich in iodine content?
Milk
Seafood
Eggs
Bananas
Beans
Meat
Leafy vegetables
Others_______________
Don’t Know
D06
Do you think your current dietary consumption consists of adequate iodine content?
Yes
No
Don’t Know
D07
In your perception, what are the characteristics of good quality salt?
It looks white
Look is attractive
Taste is good
Packaged/branded salt
Loose/unbranded salt
Powdered salt
Granular/crystal salt
No moisture content
Free flow
Iodized salt
Others________________________________
D08
In your opinion, does iodine in the salt affect its taste?
Yes
No
Don’t Know
D09
Do you know the advantages of iodized salt over non-iodized salt?
Yes
No
D10
What are benefits of the iodised salt?
Prevents Goiter
Prevents Cretinism
Prevents complication during birth
Protects child foetus
Improves intelligence levels
Improves maternal health
Others
D11
How do you usually store your salt?
Plastic container with a lid
Plastic container without a lid
Metal container with a lid
Metal container without a lid
Glass container with a lid
Glass container without a lid
Earthen pot with a cover
Earthen pot without a cover
Wooden container with a cover
Wooden container without a cover
In the same pouch
In sack/bags
Others__________________
D12
What are the ways by which iodine loss can occur? (Multiple Responses possible- )
Storing in open
By storing in a cool place
During cooking
Others (Please specify)_________________
Behavior Change Interventions (Pre-existing during baseline)
E01
Do you have access to radio or TV or mobile and where do you access in most of the time?
Yes
No
E01A
Do you have access
Yes
No
E01A1
Radio
Yes
No
E01A2
TV
Yes
No
E01A3
Mobile
Yes
No
E01B
Where do you have access
Own House
Neighbours
Community Centre/ Panchayat ghar
Friends house
Relatives house
Tea/paan shop
No fixed place
Others (Specify)
E01B1
Radio
Own House
Neighbours
Community Centre/ Panchayat ghar
Friends house
Relatives house
Tea/paan shop
No fixed place
Others (Specify)
E01B2
TV
Own House
Neighbours
Community Centre/ Panchayat ghar
Friends house
Relatives house
Tea/paan shop
No fixed place
Others (Specify)
E01B3
Mobile
Own House
Neighbours
Community Centre/ Panchayat ghar
Friends house
Relatives house
Tea/paan shop
No fixed place
Others (Specify)
E02
How often do you listen to radio, view the television, and see mobile messages on an average in a day/Sunday (holiday)? (In HOURS/ DAY) (Write Code)
Never
Every day (7 days in a week)
Regularly (4-6 days in a week)
Sometimes (2-3 days in a week)
Only Saturday/Sunday/ Holiday
E02A
Number of days per week
Never
Every day (7 days in a week)
Regularly (4-6 days in a week)
Sometimes (2-3 days in a week)
Only Saturday/Sunday/ Holiday
E02A1
Radio
Never
Every day (7 days in a week)
Regularly (4-6 days in a week)
Sometimes (2-3 days in a week)
Only Saturday/Sunday/ Holiday
E02A2
TV
Never
Every day (7 days in a week)
Regularly (4-6 days in a week)
Sometimes (2-3 days in a week)
Only Saturday/Sunday/ Holiday
E02A3
Mobile
Never
Every day (7 days in a week)
Regularly (4-6 days in a week)
Sometimes (2-3 days in a week)
Only Saturday/Sunday/ Holiday
E02B
Hours per day/Number of messages
< 1 Hour
1 – 2 Hour
2 – 3 Hour
3 – 4 Hour
> 4 Hours
E02B1
Radio
< 1 Hour
1 – 2 Hour
2 – 3 Hour
3 – 4 Hour
> 4 Hours
E02B2
TV
< 1 Hour
1 – 2 Hour
2 – 3 Hour
3 – 4 Hour
> 4 Hours
E02B3
Mobile
< 1 Hour
1 – 2 Hour
2 – 3 Hour
3 – 4 Hour
> 4 Hours
E03
When do you usually listen to radio and watch television? (Circle top two slots)
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E03A
Slot 1
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E03A1
Radio
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E03A2
TV
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E03B
Slot 2
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E03B1
Radio
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E03B2
TV
Early morning (6 AM <8 AM)
Mid – morning (8 AM <12 Noon)
Afternoon (12 Noon <4 PM)
Evening (4 PM <7 PM)
Late evening (7 PM <9 PM)
Night (9 PM <11 PM)
Late night (11 PM onwards)
E04
Which radio stations do you generally listen to?
Vivid Bharti
FM
Regional (local) station specify
Other (specify)
E05
Which Television channels do you generally watch more?
Doordarshan (National)
DD Saptagiri
ETV Telugu
Gemini TV
Zee Telugu
Maa TV
Maa Gold
Vissa TV
Star Plus
Star News
Zee News
Zee Cinema
Sony
Star Gold
NDTV
CNN IBN
Others (Specify)
E06
What are the programs you mostly listen/watch on Radio/TV? Please tell us top two slots each for Radio and TV
News
Drama/serials
Film songs
Advertisement
Discussion on health
Music
Folk Music
Films
Other (specify)
E06A
TV
News
Drama/serials
Film songs
Advertisement
Discussion on health
Music
Folk Music
Films
Other (specify)
E06B
Radio
News
Drama/serials
Film songs
Advertisement
Discussion on health
Music
Folk Music
Films
Other (specify)
E07
Do you get Mobile messages?
Yes
No
E08
In the last seven days what kind of Mobile messages did you open and see?
Job Related
Songs, Movie Related
Property and Real Estate Related
Bank/ Money Related
Jotishee / Horoscope
Travel related
Others (specify)
E09
A.Do you/ anyone in your family read/s Newspaper?
Yes
No
E10
B. If yes, which one?
E10A
Name
E10B
Language
E11
What are the various sources from where you have come to know about issues / messages related to iodized salt?
TV
Radio
Newspaper / Magazine
Hoarding / Placard / Poster / Billboards / Wall writing
Hand bills / Pamphlets / Booklets
Public Announcements
Bus
Drama / Skits / Street play / puppet show/ health exhibitions in schools
SHGs/ Health Groups (Kalyani)
Doctor
ASHA/AWW/
Friends/ Relative
At retail outlet
Others (Specify)
E11A
Source
TV
Radio
Newspaper / Magazine
Hoarding / Placard / Poster / Billboards / Wall writing
Hand bills / Pamphlets / Booklets
Public Announcements
Bus
Drama / Skits / Street play / puppet show/ health exhibitions in schools
SHGs/ Health Groups (Kalyani)
Doctor
ASHA/AWW/
Friends/ Relative
At retail outlet
Others (Specify)
E11B
Last time when did you see / hear - (days before)
E11C
Do you recall the message
Yes
No
E11D
If respondent is able to recall, what was/were the messages
E12
In how many channels you have come across messages on Iodized salt
E13
Please name the channels and tell us the specific messages.
Doordarshan (National)
DD Saptagiri
ETV Telugu
Gemini TV
Zee Telugu
Maa TV
Maa Gold
Vissa TV
Star Plus
Star News
Zee News
Zee Cinema
Sony
Star Gold
NDTV
CNN IBN
Others (Specify)
E13A
Channels
Doordarshan (National)
DD Saptagiri
ETV Telugu
Gemini TV
Zee Telugu
Maa TV
Maa Gold
Vissa TV
Star Plus
Star News
Zee News
Zee Cinema
Sony
Star Gold
NDTV
CNN IBN
Others (Specify)
E13B
Message
E14
In how many stations you have come across messages on Iodized salt?
E15
Please name the radio station and tell us the specific messages
Vivid Bharti
FM
Regional (local) station specify
Other (specify)
E15A
Station
Vivid Bharti
FM
Regional (local) station specify
Other (specify)
E15B
Message
E16
Whether the respondent was able to recognize the iodized salt slogan/key message (from any source) correctly?
Yes
No
E17
What is the source from whom/which you prefer to know about issues related to iodized salt in future?
TV
Radio
Newspaper / Magazine
Hoarding / Placard / Poster / Billboards / Wall writing
Hand bills / Pamphlets / Booklets
Public Announcements
Bus
Drama/skit/street plays/puppet shows/health exhibitions
SHGs/ Health Groups (Kalyani)
Doctor
ASHA/AWW/ANM
Friends/ Relative
At retail outlet
Don’t Know
Others (Specify)
E17A
Preference 1
TV
Radio
Newspaper / Magazine
Hoarding / Placard / Poster / Billboards / Wall writing
Hand bills / Pamphlets / Booklets
Public Announcements
Bus
Drama/skit/street plays/puppet shows/health exhibitions
SHGs/ Health Groups (Kalyani)
Doctor
ASHA/AWW/ANM
Friends/ Relative
At retail outlet
Don’t Know
Others (Specify)
E17B
Preference 2
TV
Radio
Newspaper / Magazine
Hoarding / Placard / Poster / Billboards / Wall writing
Hand bills / Pamphlets / Booklets
Public Announcements
Bus
Drama/skit/street plays/puppet shows/health exhibitions
SHGs/ Health Groups (Kalyani)
Doctor
ASHA/AWW/ANM
Friends/ Relative
At retail outlet
Don’t Know
Others (Specify)
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