12IDHS-HH
Confidential
PROVINCE
2. REGENCY/MUNICIPALITY*) 3. SUBDISTRICT
4. VILLAGE
5. URBAN/RURAL**) URBAN -1 RURAL -2
6. CENSUS BLOCK NUMBER
7. 2012 IDHS SAMPLE CODE 8. HOUSEHOLD NUMBER
9. NAME OF HOUSEHOLD HEAD
10. NAME OF RESPONDENT
11. SELECTED FOR MALE SURVEY YES -1 NO -2
RESULT***) RESULT
DATE
TOTAL NO. OF VISIT TIME
***)
RESULT CODES:
1 COMPLETED
2 TOTAL PERSONS
IN HOUSEHOLD 3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED TOTAL MARRIED
5 REFUSED MEN AGED 15-54
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER
(SPECIFY) UNMARRIED MEN
AGED 15-24
NAME
DATE
*)
Cross out category not used
TOTAL TOTAL WOMEN AGED 15-49
INT. NUMBER INTERVIEWER’S
NAME
NEXT VISIT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
DATE
MONTH 1.
LINE NUMBER OF RESPONDENT
FIELD EDITOR SUPERVISOR OFFICE EDITOR PONSER
FINAL VISIT 2
1
YEAR 2 0
2012 INDONESIA DEMOGRAPHIC AND HEALTH SURVEY
2 3
II. INTERVIEWER VISITS
DATE OF INTERVIEW
HOUSEHOLD QUESTIONNAIRE
I. IDENTIFICATION LOCATION
B
1=
*) CODES FOR COLUMN (3): RELATIONSHIP TO HEAD OF HOUSEHOLD **) CODE FOR COLUMN (13 AND 16): EDUCATION
01 = HEAD OF HOUSEHOLD 08 = BROTHER OR SISTER LEVEL: GRADE:
02 = WIFE OR HUSBAND 09 = OTHER RELATIVE 1 = PRIMARY SCHOOL 0 = FIRST YEAR 03 = CHILD 10 = ADOPTED CHILD 2 = JUNIOR HIGH SCHOOL 1-6 = GRADE 1-6 04 = SON OR DAUGHTER-IN-LAW 11 = STEPCHILD 3 = SENIOR HIGH SCHOOL 7 = COMPLETED 05 = GRANDCHILD 12 = NOT RELATED 4 = ACADEMY/ D1/D2/ D3 8 = DON'T KNOW
06 = PARENT 98 = DON’T KNOW 5 = UNIVERSITY
07 = PARENT-IN-LAW 8 = DON'T KNOW
***)CODES FOR COLUMN (17): BIRTH CERTIFICATE OWNERSHIP
1 = HAVE BIRTH CERTIFICATE 2 = REGISTERED
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS (5)-(15) FOR EACH PERSON AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTION 1-5 BELOW TO BE SURE THAT THE
LISTING IS COMPLETE. Please give me the names of the persons who
usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
Does (NAME) usually live
here?
NEVER MARRIED
NO USUAL RESIDENTS AND VISITORS
(NAME)
III. HOUSEHOLD
AGE ≥15
stay here last night?
marital status?
SCHEDULE
(9) (10) (11) (15)
YES NO LEVEL GRADE YES NO YES NO LEVEL GRADE
01 01 01 1 2 1 2 1 2
TICK HERE IF CONTIUNATION SHEET USED
YES NO
1. Are there other persons such as small children or infants ENTER EACH IN TABLE that we have not listed?
2) Are there any other people who may not be members of your ENTER EACH IN TABLE family, such as domestic servans lodgers or friends
who usually live here?
3) Are there any guests or temporary visitors staying here
or anyone else who selpt here for six monts or more, who have not ENTER EACH IN TABLE been listed?
4) Are there any other people who usually live here, but we ENTER EACH IN TABLE have been away for less than 6 months?
5) Are there any people who have been listed as members of
household have been away for less than 6 months but DELETE
AGE 5 YEARS OR OLDER AGE 5-24 YEARS
EVER ATTENDANCE
SCHOOL CURRENT/ATTEND SCHOOL RECENTLY
CIRCLE
Just to make sure that I have a complete (13)
2011 school year, what level and grade
101 DAILY . . . WEEKLY . . . MONTHLY . . . LESS THAN MONTHLY . . . NEVER . . .
102 PIPED WATER
. . . 11
. . . 12 105 PUBLIC TAP . . . 13
OPEN WELL OPEN WELL IN DWELLING . . . 21
OPEN WELL IN YARD/POLT . . . 22 105 OPEN PUBLIC WELL . . . 23
PROTECTED WELL PROTECTED WELL IN DWELLING . . . . 31
PROTECTED WELL IN YARD/PLOT . . . . 32
PROTECTED PUBLIC WELL . . . 33
SPRING . . . 41
RIVERS/STREAM . . . 42
POND/LAKE . . . 43
DAM . . . 44
RAIN WATER . . . 51
TANKER TRUCK . . . 61
71 REFILL WATER . . . 81
OTHER 96 (SPECIFY) 103 IN OWN DWELLING . . . 1
IN OWN YARD/PLOT . . . 2 105 ELSEWHERE . . . 3
104 MINUTES . . . DON'T KNOW . . . 998
105 Do you do anything to the water to make it safer to drink? YES . . . NO . . . DON'T KNOW . . . 107
106 What do you usually do to make the water safer to drink? BOIL . . . A ADD BLEACH/CHLORINE . . . B STRAIN THROUGH CLOTH . . . C USE WATER FILTER (CERAMIC/
SAND/COMPOSITE/ETC. . . D
Anything else? SOLAR DISINFECTION . . . E
LET IT STAND AND SETTLE . . . F OTHER X
DON'T KNOW . . . Z Would you say daily, weekly, monthly, less than monthly, or
never?
PIPED INTO DWELLING
BOTTLED WATER
105
105
IV. HOUSING CONDITION
SKIP TO
QUESTIONS AND FILTERS CODE
NO.
How often does anyone smoke inside your house?
PIPED INTO YARD/PLOT
1
What is the main source of drinking water for members of your households?
(SPECIFY)
. . .
How long does it take you to go there, get water, and come back?
Where is that water source located?
RECORD ALL MENTIONED.
SKIP TO
QUESTIONS AND FILTERS CODE
NO.
107 PRIVATE
WITH SEPTIC TANK . . . 11
WITH NO SEPTIC TANK 2 109A SHARED/PUBLIC . . . 21
RIVER/STREAM/CREEK . . . 31
PIT . . . 41
YARD/BUSH/FOREST . . . 51
OTHER 96 109A 109 NO. OF HOUSEHOLDS IF LESS THAN 10 . . . 10 OR MORE HOUSEHOLDS . . . 95
DON'T KNOW . . . 98
109A CHECK 102: WELL (CODE 21, 22, 23, 31, 32, 33) OTHER THAN CODE 21, 22, 23, 31, 32, 33 109B DISTANCE (IN METER . . . (ROUNDED UP IN METER). IF ≥ 95 RECORD '95' DON'T KNOW . . . 98
110 Does your household have: YES Electricity? 1 Radio? RADIO . . . 1
Television? TELEVISION
. . .
1Telephone? TELEPHONE 1 Hand phone? HAND PHONE 1 Refrigerator? REFRIGERATOR . . . 1
111 ELECTRICITY . . . 01
. . . 02
BIOGAS . . . 03
KEROSENE . . . 04
. . . 05
CHARCOAL . . . 06
WOOD . . . 07
STRAW/SHRUBS/GRASS . . . 08
AGRICULTURAL CROP . . . 09
ANIMAL DUNG . . . 10
NO FOOD COOKED IN HOUSEHOLD . . . 95
OTHER 96 112 IN THE HOUSE . . . 1
IN A SEPARATE BUILDING . . . 2
OUTDOORS . . . . . . 3
OTHER 6 113 Do you have a separate room which is used as a kitchen? YES . . . 1
NO . . . 2
110
114
114 NO
(SPECIFY) What is the distance between the well and the nearest
septic tank?
IF PRIVATE TOILET, RECORD IF CONNECTED TO SEPTIC TANK
What kind of toilet facility do members of your household usually use?
(SPECIFY)
How many households use this toilet facility?
0
. . .Is the cooking usually done in the house, in a separate building, or outdoors?
What type of fuel does your household mainly use for
cooking? LPG/NATURAL GAS
(SPECIFY)
2 2 2 2 2 2 ELECTRICITY . . .
. . . . . .
SKIP TO
QUESTIONS AND FILTERS CODE
NO.
114 MAIN MATERIAL OF THE FLOOR. NATURAL FLOOR
EARTH/SAND . . .
114A What is the floor area of this house?
. . . (IN SQUARE METERS)
DON'T KNOW . . . 998 IF ≥ 995 RECORD '995'
114B How many rooms in this household are used for sleeping? ROOMS
115 MAIN MATERIAL OF THE ROOF. NATURAL ROOFING
THATCH/PALM LEAF/SOD . . .
118 Does any member of this household own: YES
- A bicycle? A bicycle? 1 2
- A motorcycle ? A motorcycle ? 1 2
- A rowboat? A rowboat? 1 2
- A motorboat? A motorboat? 1 2
- An animal-drawn cart An animal-drawn cart
(Sado,Cidomo,dokar,Andong,Bendi)? (Sado,Cidomo,dokar,
IF 95 OR MORE, CIRCLE '950'. 95 OR MORE HECTARES 950
DON'T KNOW 998
How many hectares of agricultural land do members of this household own?
Does any member of this household own any agricultural land?
SKIP TO
QUESTIONS AND FILTERS CODE
NO.
121 YES . . .
NO . . . 123
122
Cattle? CATTLE
Milk Cows/Bulls? COWS/BULLS
Horses, donkeys, or mules? HORSES/DONKEYS/MULES
Goats/sheep? GOATS/SHEEP
Pig? PIG
Poultry? POULTRY
IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'.
123 YES 1
NO . . . 2
137 Please show me where members of your household most OBSERVED 1
NOT OBSERVED
NOT IN DWELLING/YARD/PLOT 2 NOT OBSERVED,
NO PERMISSION TO SEE 3
NOT OBSERVED,
OTHER REASON 4
138 OBSERVATION ONLY: WATER IS AVAILABLE 1
OBSERVE PRESENCE OF WATER AT THE WATER IS NOT AVAILABLE
2
PLACE FOR HANDWASHING.
139 OBSERVATION ONLY: SOAP OR DETERGENT
(BAR, LIQUID, POWDER, PASTE) A OBSERVE PRESENCE OF SOAP, DETERGENT, OR ASH, MUD, SAND . . . B
OTHER CLEANSING AGENT. NONE . . . C
. . .
. . . often wash their hands.
. . . Does this household own any livestock, herds, other farm
animals, or poultry?
How many of the following animals does this household own?
Does any member of this household have a bank account?
. . .
. . .
. . . . . .
STOP . . .
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