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Household Survey Questionnaire for the Indonesia Family Life Survey, Wave 5

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Household Survey Questionnaire for the Indonesia Family Life Survey, Wave 5 Working Paper Household Survey Questionnaire for the Indonesia Family Life Survey, Wave 5 JOHN STRAUSS, FIRMAN WITOELAR AND BONDAN SIKOKI RAND Labor & Population WR-1143/3-NIA/NICHD March 2016 RAND working papers are intended to share researchers’ latest findings and to solicit informal peer review. They have been approved for circulation by RAND Labor and Population but have not been formally edited or peer reviewed. Unless otherwise indicated, working papers can be quoted and cited without permission of the author, provided the source is clearly referred to as a working paper. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. is a registered trademark. For more information on this publication, visit www.rand.org/pubs/working_papers/WR1143z3.html Published by the RAND Corporation, Santa Monica, Calif. © Copyright 2016 RAND Corporation R® is a registered trademark Limited Print and Electronic Distribution Rights This document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions.html. The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest. RAND’s publications do not necessarily reflect the opinions of its research clients and sponsors. Support RAND Make a tax-deductible charitable contribution at www.rand.org/giving/contribute www.rand.org CONFIDENTIAL INTERVIEWER: ______________________________________ …└─┴─┴─┘ EA : └─┴─┴─┘ HHID : └─┴─┴─┘└─┴─┘└─┴─┘└─┴─┘ Informed Consent (to be read to each individual the first time the individual is interviewed): health, retirement and social security policies suitable for Indonesia, which will benefit you and other people just like you. Good morning/afternoon/evening, The interview is completely voluntary and all survey information will be kept confidential. With My name is _____________ and my colleague here is _______________. We are both from your consent, we also will take picture of you and the front of your house solely for the purpose of SurveyMeter, an independent research organization based in Yogyakarta. We are currently confirming your identity and your address in the follow up survey. The photos and all your personal conducting the fieldwork for Sakerti 5, a survey project conducted with collaboration with RAND records including, questionnaires, and physical examination and test results are confidential; we will Corporation. We will start by reading the informed consent form and ask whether you would be not tell others, include your family, friends, local hospitals, etc. Your personal information, including willing to participate in the survey. You can ask about anything that is not clear at any time. Please do name, address, phone number, and other information which can be used to identify you will not be discuss with your family members before deciding to participate in the survey. disclosed. You are identified by a number in the questionnaires and test records, which will be stored safely in IFLS5 project office. You may withdraw from the study any time, which will not impact any The IFLS is a longitudinal survey that was first fielded in 1993, and again in 1997, 2000, and 2007. of your benefits. The researcher will keep your information confidentially until it is destroyed, and You may remember that we visited your households to interview you or your household members in your information will not be used or disclosed during this period. 2007 or in an earlier round. Your household was interviewed since it was one of the households or part of the households that were randomly chosen to participate since the beginning of the survey in If you agree to participate in this study, all the interviews, physical examination, tests and counseling 1993. This year, we will visit the same households again to conduct the interview and to see whether are provided to you for free. You do not need to pay anything. there have been some changes since the last time we visited you. If you agree to participate in this study, you will get Rp _________________ as a token gift of If you choose to participate in the study, our interviewer will first ask you about your basic appreciation for the time you spend with us. demographics, family information, health status, health care and insurance, work, retirement and pensions, household and individual income, expenditure, and assets, etc. Then the interviewer will If you have any questions about this study, you may contact Bondan Sikoki at SurveyMETER at give you a physical examination to better understand your true health conditions. The measurements email address: [email protected] atau telpon 62-274-4477464 dan fax: 62-274-4477004 include height, weight, waist circumference, blood pressure, peak meter flow lung capacity, grip strength, balance, timed walk, and timed sit to stand. We will also do a finger prick to measure your Interviewer’s Statement blood hemoglobin level [and to collect blood spot on a filter paper which we will store and use in the “I have informed the respondent about the background, goals, procedure, risks and benefits of the lab for analysis of C-reactive Protein that can be used to measure inflammation and the risk to survey, given him/her enough time to read the informed consent and discuss with others, and cardiovascular diseases and HbA1c that can be used to measure risk of diabetes]. answered all questions related to the survey; I have informed the respondent that he/she can contact the SurveyMETER, when having problems about the surveand provided the accurate contact This survey will take some time to complete, but we will be doing it at your convenience. If you need information. I have informed the respondent that he/she can withdraw from the survey anytime. I to take a break or run some errands, please let us know so we can stop the interview and continue have informed the potential respondent that he/she can get a copy of this informed consent with later in the day or the next day. signatures of mine.” Generally, the study will pose no health risk. The blood drawing procedure will not transmit diseases □ Signed by interviewer. Interviewer name: _______ day/month/year to you, because the syringe and needle are new and disinfected. The small amount of blood drawn has no harm to your health. There maybe discomfort or very mild pain, we will help you deal with it. Respondent’s statement: If you agree to participate in the survey, the physical examination and test results related to your “I have been read the informed consent and I agree to participate in”: □ questionnaire survey health will be feed back to you directly. And the information you provided can be used to help make BT_COV BOOK T - 1 IFLS5 CONFIDENTIAL INDONESIAN FAMILY LIFE SURVEY 2014 BOOK T (TRACKING BOOK) SECTION: SC BOOK T OF └─┘ TB1. What is the final result of the Interviewed ........................................ 1 INTERVIEWER CHECK FROM FORM T1 ANSWER, IF FORM T1 IS COMPLETED interview? Refused ............................................. 2 INTERVIEWER CHECK Died ................................................... 4 TB3 D1. Is information on new address/location at Form T1 adequate? Household was not found ................. 5 TB5 Yes ............................................................................... 1 Household not able to meet .............. 6 TB3 No ................................................................................ 3 Joined with other IFLS household .... 3 “Moved out HH” confirmation ........... 8TB3 D2 Where is the new location? Same village ................................................................ 01 TB2. What is the HHID for this joined └─┴─┴─┘└─┴─┘└─┴─┘└─┴─┘ INTERVIEWER CHECK Same sub-district ......................................................... 02 IFLS household ? Same district ................................................................ 03 Same province ............................................................. 04 TB3. What’s the name of the informant ___________________________ Outside province _____________________________ 05 ? DK, information is not adequate .................................. 08 TB4. Relationship of informant with the Neighbor ........................................... 1 household. Family ............................................... 2 Friend ................................................ 3 D3. Number of Form T1 for this Book T? └─┘ Head of RT/RW ................................ 4 INTERVIEWER CHECK TB5. Where does the new address for Address book .................................... 1 tracking from? Form T1 ............................................ 3 TB6. Is the (physical) building found ? Yes .................................................... 1 No, information is not complete ........ 3 Other ________________________ 5 INTERVIEWER CHECK CODE OF INTERVIEW’S RESULT: INTERVIEWER CHECK: 1. Interviewed IF TB1 = 1 BOOK K 2. Refused
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