PROGRAMA ESCUCHAR LISTING BASELINE QUESTIONNAIRE HOUSEHOLD-LEVEL SURVEY Language 1 English 2 Spanish 3 Mayan 4 Proxy Spanish | IF CH013_date = EMPTY THEN 5 Proxy Mayan | 6 Proxy English | ENDIF | < > Different to | [Questions CH029 to CH019 are displayed as a table] | | CH029 | FormID | String | | CH013 | What is the name of the interviewer who collected this listing? | String | | CH013_b | # | Integer | | CH013_date | Date | String | | CH001 | Can you please give me your complete address? [IWER: PLEASE LIST | STREET NAME AND HOUSE NUMBER] | String | | CH001_a | Street | String | | CH001_b | Number | String | | CH001_c | cross streets | String | | CH001_d | cross streets | String | | CH002 | City | String | | CH003 | Municipality | 1 Abalá | 2 Acanceh | 3 Akil | 4 Baca | 5 Bokobá | 6 Buctzotz | 7 Cacalchén | 8 Calotmul | 9 Cansahcab | 10 Cantamayec | 11Celestún | 12 Cenotillo | 13 Conkal | 14 Cuncunul | 15 Cuzamá | 16 Chacsinkín | 17 Chankom | 18 Chapab | 19 Chemax | 20 Chicxulub Pueblo | 21 Chichimilá | 22 Chikindzonot | 23 Chocholá | 24 Chumayel | 25 Dzán | 26 Dzemul | 27 Dzidzantún | 28 Dzilam de Bravo | 29 Dzilam González | 30 Dzitás | 31 Dzoncauich | 32 Espita | 33 Halachó | 34 Hocabá | 35 Hoctún | 36 Homún | 37 Huhí | 38 Hunucmá | 39 Ixil | 40 Izamal | 41 Kanasín | 42 Kantunil | 43 Kaua | 44 Kinchil | 45 Kopomá | 46 Mama | 47 Maní | 48 Maxcanú | 49 Mayapán | 50 Mérida | 51 Mocochá | 52 Motul | 53 Muna | 54 Muxupip | 55 Opichén | 56 Oxkutzcab | 57 Panabá | 58 Peto | 59 Progreso | 60 Quintana Roo | 61 Río Lagartos | 62 Sacalum | 63 Samahil | 64 Sanahcat | 65 San Felipe | 66 Santa Elena | 67 Seyé | 68 Sinanché | 69 Sotuta | 70 Sucilá | 71 Sudzal | 72 Suma | 73 Tahdziú | 74 Tahmek | 75 Teabo | 76 Tecoh | 77 Tekal de Venegas | 78 Tekantó | 79 Tekax | 80 Tekit | 81 Tekom | 82 Telchac Pueblo | 83 Telchac Puerto | 84 Temax | 85 Temozón | 86 Tepakán | 87 Tetiz | 88 Teya | 89 Ticul | 90 Timucuy | 91 Tinum | 92 Tixcacalcupul | 93 Tixkokob | 94 Tixmehuac | 95 Tixpéhual | 96 Tizimín | 97 Tunkás | 98 Tzucacab | 99 Uayma | 100 Ucú | 101 Umán | 102 Valladolid | 103 Xocchel | 104 Yaxcabá | 105 Yaxkukul | 106 Yobaín | | CH016 | Neighborhood | String | | CH020 | Meter | String | | CH014 | Block number | String | | CH015 | Listing number | Integer | | CH018 | AGEB | String | | CH019 | Other comments about the address (description etc) | String | | [Questions CH004 to CH028 are displayed as a table] | | CH004 | When would be the best day and time for us to come back to give you more | information about the study and if you are interested, to complete the | interview? | | String | | CH017 | Or appointment-general indication | String | | CH006 | Can you please give me your telephone number? | String | | CH005 | We can conduct the interview either in Spanish or Mayan. What language | would the persons who are 65 years or older in this household prefer to speak? | 1 Spanish | 2 Mayan | 3 Some in Spanish, some in Mayan | | CH028 | How many people over 65 years old live in this household? | Range: 1..10 | | LOOP FROM 1 TO [NUMBER OF PEOPLE OVER 65] DO | | [Questions CH007_a[over65cnt] to CH008_e[over65cnt] are displayed as a table] | | CH007_a | Could you please give me the name of the [oldest/second/third/fourth/fifth | sixth/seventh/eigth/nineth/tenth] person in the household (over 65?) Please | give me their name as it appears on their birth certificate. [IWER: PRINT | FIRST AND LAST NAMES] | String | | CH007_b | Could you please give me the name of the oldest person in the household (over | 65?) Please give me their name as it appears on her/his birth certificate. | [IWER: PRINT FIRST AND LAST NAMES] | String | | CH007_c | Could you please give me the full name of the oldest person in the household | (over 65?) Please give me her/his name as it appears on her/his birth certificate. | [IWER: PRINT FIRST AND LAST NAMES] | String | | CH008_a | What is his/her date of birth? | Range: 1..31 | | CH008_b | 1 January | 2 February | 3 March | 4 April | 5 May | 6 June | 7 July | 8 August | 9 September | 10 October | 11 November | 12 December | | CH008_c | Range: 1890..2007 | | CH008_d | OR Age: | Range: 0..120 | | CH008_e | Gender | 1 Male | 2 Female | | [Questions CH009[over65cnt] to CH012[over65cnt] are displayed as a table] | | CH009 | Will [FIRST NAME OLDEST RESPONDENT 65 PLUS] be able to participate in the | interview? | 1 Yes | 2 No | | CH010 | Is there someone else in this household who knows about the health and daily | life of [FIRST NAME OLDEST RESPONDENT 65 PLUS] that could answer the | interview in her/his instead? | 1 No | 2 Yes -> Fill out name and relationship below | | CH011 | What is this person’s name? | String | | CH012 | How is this person related to [FIRST NAME OLDEST RESPONDENT 65 PLUS]? | 2 Husband/wife | 3 Son/daughter | 4 Stepson/Stepdaughter | 5 Adopted son/daughter | 6 Person was taken in | 7 Mother/father | 8 Father-in-law/ mother-in-law | 9 Grandmother/grandfather | 10 Grandson/granddaughter | 11 Great grandson/ great granddaughter | 12 Son-in-law/ daughter-in-law | 13 Brother/ stepbrother/sister/stepsister | 14 Brother-in-law/ sister-in-law | 15 Uncle/aunt | 16 Nephew/niece | 17 Other relative | 18 Not related | | ENDDO .