QUESTIONNAIRES APPENDIX E Appendix E | 263 AUTHORITY: Commonwealth Act No. 591 authorizes this survey and the Philippines National PHILIPPINES NATIONAL STATISTICS OFFICE NDHS Form 1 Statistics Office to collect information on fertility, NSCB Approval No. NSO-0305-01 family planning and health. 2003 NATIONAL DEMOGRAPHIC AND Expires March 31, 2004 CONFIDENTIALITY: Sec. 4 of CA No. 591 provides HEALTH SURVEY that all information furnished on this form is held STRICTLY CONFIDENTIAL. HOUSEHOLD QUESTIONNAIRE Set _____ of_____ sets IDENTIFICATION PROVINCE CITY/MUNICIPALITY_____________________________________________________________________ BARANGAY ____________________________________________________________________________ URBAN/RURAL (URBAN=1, RURAL=2)............................................................................................................. REPLICATE ......................................................................................................................................................... PSU...................................................................................................................................................................... EA ........................................................................................................................................................................ STRATUM............................................................................................................................................................ HOUSEHOLD CONTROL NUMBER ................................................................................................................... NDHS HOUSEHOLD SEQUENTIAL NUMBER................................................................................................... SELECTED FOR MALE SURVEY 1 YES 2 NO NAME OF HOUSEHOLD HEAD ADDRESS _____________________________________________________________________________ INTERVIEW RECORD 1 2 3 FINAL VISIT DATE DAY MONTH INTERVIEWER’S NAME YEAR 2 0 0 3 RESULT* INTERVIEWER CODE NEXT VISIT: DATE RESULT* TIME TOTAL NO. OF VISITS *RESULT CODES: TOTAL HOUSEHOLD MEMBERS AND 01 COMPLETED, ORIGINAL HOUSEHOLD LANGUAGE OF QUESTIONNAIRE** 7 VISITORS 02 COMPLETED, PRESENT OCCUPANT OF LOCAL LANGUAGE OF TOTAL ELIGIBLE DWELLING RESPONDENT** WOMEN 03 NO HOUSEHOLD MEMBER AT HOME OR NO TOTAL ELIGIBLE COMPETENT RESPONDENT AT HOME AT LANGUAGE OF INTERVIEW** TIME OF VISIT MEN 04 ENTIRE HOUSEHOLD ABSENT FOR TRANSLATOR USED YES 1 LINE NO. OF EXTENDED PERIOD OF TIME NO 2 RESPONDENT TO THE HOUSEHOLD 05 POSTPONED QUESTIONNAIRE 06 REFUSED **LANGUAGE CODES TIME OF INTERVIEW 07 DWELLING VACANT OR ADDRESS NOT A 1 TAGALOG 5 HILIGAYNON DWELLING TIME STARTED HR 2 CEBUANO 6 WARAY 08 DWELLING DESTROYED MIN 3 ILOCANO 7 ENGLISH 09 DWELLING NOT FOUND TIME ENDED HR 10 OTHER 4 BICOL 8 OTHER______________ (SPECIFY) (SPECIFY) MIN SUPERVISOR FIELD EDITOR OFFICE EDITOR ENCODER Name and Signature Date Name and Signature Date Appendix E | 265 HOUSEHOLD SCHEDULE Now I would like to ask you some information about the people who usually live in your household or who are staying with you now. RELATIONSHIP TO HEAD SEX RESIDENCE AGE ELIGIBILITY USUAL RESIDENTS AND VISITORS OF THE HOUSEHOLD** LINE CIRCLE CIRCLE NO. LINE LINE Please give me the names of the persons What is the Is (NAME) Does Did How old is NUMBER NUMBER who usually live in your household and relationship of male or (NAME) (NAME) (NAME) as OF ALL OF ALL guests of the household who slept here last (NAME) to the female? usually live sleep here of his/her WOMEN MEN night, starting with the head of the head of the here? last night? last AGE AGE household. household? birthday? 15-49 15-54 (1) (2) (3) (4) (5) (6) (7) (8) (9) M F Y N Y N IN YEARS 01 1 2 1 2 1 2 01 01 02 1 2 1 2 1 2 02 02 03 1 2 1 2 1 2 03 03 04 1 2 1 2 1 2 04 04 05 1 2 1 2 1 2 05 05 06 1 2 1 2 1 2 06 06 07 1 2 1 2 1 2 07 07 08 1 2 1 2 1 2 08 08 09 1 2 1 2 1 2 09 09 10 1 2 1 2 1 2 10 10 11 1 2 1 2 1 2 11 11 12 1 2 1 2 1 2 12 12 1) Are there any other persons such as small children or infants that we have not listed? YES ENTER EACH IN TABLE NO 2) In addition, 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 ENTER EACH IN TABLE NO 3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed? YES ENTER EACH IN TABLE NO TICK HERE IF CONTINUATION SHEET IS USED **CODES FOR Q.3 RELATIONSHIP TO HEAD OF HOUSEHOLD: 01 = HEAD 04 = SON-IN-LAW OR DAUGHTER-IN-LAW 07 = PARENT-IN-LAW 10 = ADOPTED/FOSTER/STEPCHILD 02 = WIFE OR HUSBAND 05 = GRANDCHILD 08 = BROTHER OR SISTER 11 = NOT RELATED 03 = SON OR DAUGHTER 06 = PARENT 09 = OTHER RELATIVE 98 = DON’T KNOW 266 | Appendix E HOUSEHOLD SCHEDULE EDUCATION IF AGE IS 5 YEARS OR OLDER IF ATTENDED SCHOOL IF AGE IS 5–24 YEARS LINE NO. CURRENT SCHOOL YEAR PREVIOUS SCHOOL YEAR What is the highest Has (NAME) ever During the school During this school During the school During that school grade/year (NAME ) attended school? year June 2003- year, what grade/year year June 2002-April year, what completed?*** April 2004, is is (NAME) 2003, did (NAME) grade/year did (NAME) attending attending?*** attend school at any (NAME) attend?*** school at any time? time? (10) (11) (12) (13) (14) (15) YES NO GRADE/YEAR YES NO GRADE/YEAR YES NO GRADE/YEAR 01 1 2 1 2 1 2 GO TO NEXT HHOLD GO TO 14 GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 MEMBER, ELSE GO TO 16 1 2 1 2 02 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 03 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 04 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 05 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 06 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 07 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 08 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 09 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 10 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 11 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 1 2 1 2 12 1 2 GO TO NEXT HHOLD GO TO NEXT HHOLD MEMBER, ELSE GO TO 16 GO TO 14 MEMBER, ELSE GO TO 16 ***CODES FOR Q. 11, 13 and 15 GRADE/YEAR: 00 = NO GRADE COMPLETED 21 = HIGH SCHOOL YEAR 1 41 = COLLEGE YEAR 1 01 = PRE-SCHOOL 22 = HIGH SCHOOL YEAR 2 42 = COLLEGE YEAR 2 11 = ELEMENTARY GRADE 1 23 = HIGH SCHOOL YEAR 3 43 = COLLEGE YEAR 3 12 = ELEMENTARY GRADE 2 24 = HIGH SCHOOL YEAR 4 44 = COLLEGE YEAR 4 13 = ELEMENTARY GRADE 3 25 = HIGH SCHOOL YEAR 5 45 = COLLEGE YEAR 5 14 = ELEMENTARY GRADE 4 26 = HIGH SCHOOL GRADUATE 46 = COLLEGE YEAR 6 OR HIGHER 47 = COLLEGE GRADUATE 15 = ELEMENTARY GRADE 5 31 = POSTSECONDARY YEAR 1 16 = ELEMENTARY GRADE 6 32 = POSTSECONDARY YEAR 2 OR MORE 51 = POST BACCALAUREATE 17 = ELEMENTARY GRADE 7 98 = DON’T KNOW 18 = ELEMENTARY GRADUATE Appendix E | 267 NO. QUESTIONS AND FILTERS CODING CATEGORIES SKIP 16 Does your household or any member of your household have: YES NO Electricity? ELECTRICITY ..............................1 2 A radio/radio cassette? RADIO/RADIO CASSETTE..........1 2 A television? TELEVISION ................................1 2 A landline telephone? LANDLINE TELEPHONE .............1 2 A cellular phone? CELLULAR PHONE .....................1 2 A washing machine? WASHING MACHINE...................1 2 A refrigerator/freezer? REFRIGERATOR/FREEZER ......1 2 A CD/VCD/DVD player? CD/VCD/DVD PLAYER................1 2 A component/karaoke? A personal computer? COMPONENT/KARAOKE............1 2 PERSONAL COMPUTER ............1 2 17 Does your household or any member of your household own: YES NO A tractor? TRACTOR ....................................1 2 A motorized banca/boat? MOTORIZED BANCA/BOAT........1 2 A car/jeep/van? CAR/JEEP/VAN............................1 2 A motorcycle/tricycle? MOTORCYCLE/TRICYCLE .........1 2 A bicycle/pedicab? BICYCLE/PEDICAB .....................1 2 18 What is the main source of drinking water for members of your COMMUNITY WATER SYSTEM household? PIPED INTO DWELLING....................................... 11 19A YARD/PLOT ..................................... 12 PUBLIC TAP .................................... 13 POINT SOURCE PROTECTED WELL ............................. 21 UNPROTECTED (OPEN DUG WELL) . 22 DEVELOPED SPRING............................. 31 UNDEVELOPED SPRING........................ 32 RIVER/STREAM/POND/LAKE/DAM........ 33 BOTTLED WATER/REFILLING STATION................................................ 41 RAINWATER............................................ 51 TANKER TRUCK/PEDDLER.................... 61 19A OTHER 96 (SPECIFY) 19 How long does it take you to go there, get water, and come back? MINUTES ................................................11 ON PREMISES ....................................996 USUALLY ALWAYS AVAILABLE..............1 19A In the last month, how frequently is water available from (SOURCE IN Q.18)? SEVERAL HOURS PER DAY ...................2 ONCE OR TWICE A WEEK ......................3 INFREQUENTLY.......................................4 20 How do you make your water safe for drinking? BOILING..................................................