2012 INDONESIA DEMOGRAPHIC AND HEALTH SURVEY
12IDHS-HH 2012 INDONESIA DEMOGRAPHIC AND HEALTH SURVEY HOUSEHOLD QUESTIONNAIRE Confidential
I. IDENTIFICATION LOCATION 1.
PROVINCE
2. REGENCY/MUNICIPALITY*)
3. SUBDISTRICT
4. VILLAGE
5. URBAN/RURAL**) URBAN -1 RURAL -2 B
6. CENSUS BLOCK NUMBER 7. 2012 IDHS SAMPLE CODE
8. HOUSEHOLD NUMBER
9. NAME OF HOUSEHOLD HEAD LINE NUMBER OF RESPONDENT
10. NAME OF RESPONDENT
11. SELECTED FOR MALE SURVEY YES -1 NO -2
II. INTERVIEWER VISITS
1
2
3 FINAL VISIT DATE DATE OF INTERVIEW MONTH YEAR
2
1
2 INTERVIEWER’S INT.
NAME NUMBER
- )
RESULT RESULT DATE TOTAL NO. OF VISIT NEXT VISIT TIME
- )
RESULT CODES:
1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME TOTAL PERSONS AT TIME OF VISIT
IN HOUSEHOLD
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
TOTAL MARRIED
5 REFUSED MEN AGED 15-54 DWELLING VACANT OR ADDRESS NOT A DWELLING
6
7 DWELLING DESTROYED TOTAL WOMEN AGED 15-49
8 DWELLING NOT FOUND
9 OTHER TOTAL (SPECIFY) UNMARRIED MEN AGED 15-24
FIELD EDITOR SUPERVISOR OFFICE EDITOR PONSER
NAME DATE- )
Cross out category not used
- )
Circle the seledted category and enter in box
- ) SEE CODES BELOW
LIVING TOGETHER AGE MUST BE FILLED.
2
1
2
1
2
1
13
2
1
2
1
2
1
12
1
01 = HEAD OF HOUSEHOLD 08 = BROTHER OR SISTER
2
1
2
1
11
2
1
2
1
2
1
10
2
2
2 = JUNIOR HIGH SCHOOL 1-6 = GRADE 1-6
02 = WIFE OR HUSBAND 09 = OTHER RELATIVE 1 = PRIMARY SCHOOL 0 = FIRST YEAR 03 = CHILD 10 = ADOPTED CHILD
RELATIONSHIP TO HEAD OF HOUSEHOLD
1
IF LESS THAN
IF 95 OR MORE RECORD 95'
AGE
(NAME)'s current marital status?
ENCIRCLE ONE OF THE CODE What is
(NAME)? Did (NAME) stay here last night?
ENCIRCLE ONE OF THE CODE How old is
What is the relationship of (NAME) to the head of the household?
III. HOUSEHOLD AGE ≥15
RESIDENCE
ENCIRCLE ONE OF THE CODES
SEX
USUAL RESIDENTS AND VISITORS (NAME)
2
NEVER MARRIED NO
Does (NAME) usually live here?
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.
Is (NAME) male or female?
QUESTION 1-5 BELOW TO BE SURE THAT THE LISTING IS COMPLETE.
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS (5)-(15) FOR EACH PERSON
MARITAL STATUS
(3) (4) (8) (5) (7) (6)
1 = HAVE BIRTH CERTIFICATE 2 = REGISTERED 3 = NEITHER 8 = DON'T KNOW
8 = DON'T KNOW
06 = PARENT 98 = DON’T KNOW 5 = UNIVERSITY 07 = PARENT-IN-LAW
4 = ACADEMY/ D1/D2/ D3 8 = DON'T KNOW
04 = SON OR DAUGHTER-IN-LAW 11 = STEPCHILD 3 = SENIOR HIGH SCHOOL 7 = COMPLETED 05 = GRANDCHILD 12 = NOT RELATED
1
1
2
2
2
1
2
1
04
2
1
2
1
2
1
03
1
2
2
1
2
1
02
2
1
2
1
2
1
01
M F YES NO YES NO YEARS
1
05
1= 2= MARRIED 3= 4= DIVORCED 5= SEPARATED 6= WIDOWED
2
1
09
2
1
2
1
2
1
08
2
1
2
1
1
1
07
2
1
2
1
2
1
06
2
1
2
1
2
RECORD '00' (1) (2)
- *) CODES FOR COLUMN (3): RELATIONSHIP TO HEAD OF HOUSEHOLD **) CODE FOR COLUMN (13 AND 16): EDUCATION
LEVEL: GRADE:
- ***)CODES FOR COLUMN (17): BIRTH CERTIFICATE OWNERSHIP
- ) SEE CODES
- ) SEE CODES
- ) SEE
1
11
11
1
2
1
2
2
2
12
12
12
1
2
1
2
11
1
2
2
09
09
09
1
2
1
1
2
2
10
10
10
1
2
1
1
13
1
(16) (17) (14)
Has (NAME) ever attended school?
Did (NAME) attend school recently?
Just to make sure that I have a complete (13) (12)
IF CODE ‘2' IS
CIRCLED, GO TO NEXT HOUSEH OLD MEMBER
What is (NAME) highest grade completed? CIRCLE LINE NUMBER OF ALL WOMAN, AGED 15-49 YEARS
BELOW
ELIGIBILITY BIRTH REGISTRATI ON
CODES BELOW Has (NAME) ever been registered to the Civil
Registration Office?
During the 2010- 2011 school year, what level and grade
[is/was] (NAME) attending?
IF CODE ‘2' IS CIRCLED, GO
TO NEXT HOUSEHOLD MEMBER Did (NAME) attend school at any time during the 2010-2011 school year?
IF CODE ‘1' IS CIRCLED, GO
What is (NAME) highest level completed/ attended?
BELOW
13
2 TICK HERE IF CONTIUNATION SHEET USED YES NO
13
1
2
1
2
1
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
CIRCLE LINE NUMBER OF ALL MARRIED MAN,AGED 15-54 YEARS
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 intended to move?
AGE 5 YEARS OR OLDER AGE 5-24 YEARS EVER ATTENDANCE SCHOOL
CURRENT/ATTEND SCHOOL RECENTLY CIRCLE LINE NUMBER OF ALL NEVER MARRIED MAN, AGED 15-
24 YEARS AGE 0-4
Does (NAME) have a birth certificate?
IF ‘NO’, ASK:
2
2
SCHEDULE
03
1
2
1
2
03
03
1
1
2
1
2
1
2
04
04
2
02
1
01
(9) (10) (11) (15) YES NO
LEVEL
GRADE YES NO YES NO
LEVEL
GRADE
01
01
02
1
2
1
2
1
2
02
04
2
1
1
2
07
07
07
1
2
2
2
1
2
08
08
08
1
2
1
1
1
2
2
1
2
05
05
05
1
1
2
2
1
2
06
06
06
1
TO NEXT HOUSEHOLD MEMBER
IV. HOUSING CONDITION
NO. QUESTIONS AND FILTERS CODE SKIP TO 101 DAILY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 How often does anyone smoke inside your house? WEEKLY . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 MONTHLY . . . . . . . . . . . . . . . . . . . . . . . . . .
3 Would you say daily, weekly, monthly, less than monthly, or LESS THAN MONTHLY . . . . . . . . . . . . . . .
4 never? NEVER . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5 PIPED WATER 102 What is the main source of drinking water for members of your PIPED INTO DWELLING . . . . . . . . . . . . . . 11 households?
PIPED INTO YARD/PLOT 105 . . . . . . . . . . . . . . 12 PUBLIC TAP . . . . . . . . . . . . . . . . . . . . .
13 OPEN WELL OPEN WELL IN DWELLING . . . . . . . . . . 21 105
OPEN WELL IN YARD/POLT . . . . . . . . . . 22 OPEN PUBLIC WELL . . . . . . . . . . . . . .
23 PROTECTED WELL PROTECTED WELL IN DWELLING . . . . 31 105
PROTECTED WELL IN YARD/PLOT . . . . 32 PROTECTED PUBLIC WELL . . . . . . . . . . 33 SPRING . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 RIVERS/STREAM . . . . . . . . . . . . . . . . . . . . .
42 POND/LAKE . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 DAM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44 RAIN WATER . . . . . . . . . . . . . . . . . . . . . . . . . 51 105 TANKER TRUCK . . . . . . . . . . . . . . . . . . . . . . . 61 BOTTLED WATER . . . . . . . . . . . . . . . . . . .
71 REFILL WATER . . . . . . . . . . . . . . . . . . . . . . . 81 OTHER 96 (SPECIFY) 103 Where is that water source located?
IN OWN DWELLING . . . . . . . . . . . . . . . . . 1
IN OWN YARD/PLOT . . . . . . . . . . . . . . . 2 105 ELSEWHERE . . . . . . . . . . . . . . . . . . . . . . 3 104 How long does it take you to go there, get water, and come back?
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 BOIL . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A What do you usually do to make the water safer to drink? 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 (SPECIFY)
RECORD ALL MENTIONED.
DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . . Z
NO. QUESTIONS AND FILTERS CODE SKIP TO
107 What kind of toilet facility do members of your household PRIVATE usually use? WITH SEPTIC TANK . . . . . . . . . . . . . . . 11 WITH NO SEPTIC TANK . . . . . . . . . . . . . 2 109A SHARED/PUBLIC . . . . . . . . . . . . . . . . . . . . . .
21 IF PRIVATE TOILET, RECORD IF CONNECTED TO SEPTIC TANK RIVER/STREAM/CREEK . . . . . . . . . . . . . . . 31 PIT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 YARD/BUSH/FOREST . . . . . . . . . . . . . . . . . 51
109A OTHER
96 (SPECIFY) 109 How many households use this toilet facility? NO. OF HOUSEHOLDS IF LESS THAN 10 . . . . . . . . .
10 OR MORE HOUSEHOLDS . . . . . . . 95 DON'T KNOW . . . . . . . . . . . . . . . . . . .
98 109A CHECK 102: WELL
110 (CODE 21, 22, 23, 31, 32, 33) OTHER THAN CODE 21, 22, 23, 31, 32, 33 109B What is the distance between the well and the nearest septic tank?
DISTANCE (IN METER . . . . . . . . . . . (ROUNDED UP IN METER). IF DON'T KNOW . . . . . . . . . . . . . . . . . . . . . . . .
98 ≥ 95 RECORD '95' 110 Does your household have:
YES NO Electricity? ELECTRICITY . . . . . . . . . . . . . . .
1
2 Radio? RADIO . . . . . . . . . . . . . . . . . . . . . . 1
2 Television? TELEVISION
1
2 . . . . . . . . . . . . . Telephone? TELEPHONE . . . . . . . . . . . . . . .
1
2 Hand phone? HAND PHONE . . . . . . . . . . . . . . .
1
2 Refrigerator? REFRIGERATOR . . . . . . . . . . . . . 1
2 111 What type of fuel does your household mainly use for ELECTRICITY . . . . . . . . . . . . . . . . . . . . . . . .
01 cooking? LPG/NATURAL GAS . . . . . . . . . . . . . . . . . 02 BIOGAS . . . . . . . . . . . . . . . . . . . . . . . . . . . . 03 KEROSENE . . . . . . . . . . . . . . . . . . . . . . . .
04 COAL, LIGNITE . . . . . . . . . . . . . . . . . . . . . . . .
05 CHARCOAL . . . . . . . . . . . . . . . . . . . . . . . . . . 06 WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . 07 STRAW/SHRUBS/GRASS . . . . . . . . . . . 08 AGRICULTURAL CROP . . . . . . . . . . . . . . . 09 ANIMAL DUNG . . . . . . . . . . . . . . . . . . . . . . . .
10 NO FOOD COOKED IN HOUSEHOLD . . . . . 95 114
96 OTHER (SPECIFY) Is the cooking usually done in the house, in a separate 112
IN THE HOUSE . . . . . . . . . . . . . . . . . . . . . . 1 building, or outdoors?
IN A SEPARATE BUILDING . . . . . . . . . . . . . 2 OUTDOORS . . . . . . . . . . . . . . . . . . . . . . . 3 114
6 OTHER (SPECIFY) 113
YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Do you have a separate room which is used as a kitchen? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
SKIP TO QUESTIONS AND FILTERS CODE NO.
11
11
22
96
12
32
31
32
33
34
35
11
32
33
34
96 SQUARE METERS . . . . . . . . . . . . . . . . . . . . . . (SPECIFY) . . . . . . . . . . . .
12
96
(SPECIFY) How many hectares of agricultural land do members of this household own?
. . . . .
22
31
21 . . . . . . . . . . . . . . . . . .
FINISHED WALLS
. . . . . . . . . . . . . .
. . . . . . . . . . . .
(SPECIFY) . . . . . . . . .
Does any member of this household own any agricultural land? . . . . . . . . . . .
NO . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
31
114 MAIN MATERIAL OF THE FLOOR. NATURAL FLOOR EARTH/SAND . . . . . . . . . . . . . . . . . . .
RUDIMENTARY FLOOR [DON'T HAVE TO ASKED, JUST SEE THEN CIRCLE WOOD/PLANK . . . . . . . . . . . . . . . . . . . THE APROPRIATE CODE] BAMBOO . . . . . . . . . . . . . . . . . . . . . . . . . .
FINISHED FLOOR PARQUET . . . . . . . . . . . . . . . . . . . . . . . .
CERAMIC/MARBLE/GRANITE . . . . . . . . . TILE/TILES/TERRAZZO . . . . . . . . . . . . . CEMENT/BRICK . . . . . . . . . . . . . . . . . . .
OTHER 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 . . . . . . . . .
RUDIMENTARY ROOFING WOOD/SIRAP . . . . . . . . . . . . . . . . . . .
BAMBOO . . . . . . . . . . . . . . . . . . . . . . . . . . FINISHED ROOFING (RECORD OBSERVATION). ZINK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ASBESTOS . . . . . . . . . . . . . . . . . . . . . . TILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . CONCRETE . . . . . . . . . . . . . . . . . . . . . . METAL TILES . . . . . . . . . . . . . . . . . . . . . . OTHER NATURAL WALLS BAMBOO . . . . . . . . . . . . . . . . . . . . . . . . . . .
116 MAIN MATERIAL OF THE EXTERIOR WALLS. WOOD STEM . . . . . . . . . . . . . . . . . . . . . . BAMBOO MATTING . . . . . . . . . . . . . . . . .
(RECORD OBSERVATION). WOOD . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BRICK . . . . . . . . . . . . . . . . . . . . . . . . . . . . . OTHER 118 Does any member of this household own:
YES
- A bicycle? A bicycle?
1
2
- A motorcycle ? A motorcycle ?
2
1
2
1
2
1
2
1
- A rowboat? A rowboat?
- A motorboat? A motorboat?
- An animal-drawn cart An animal-drawn cart (Sado,Cidomo,dokar,Andong,Bendi)? (Sado,Cidomo,dokar, Andong,Bendi)?
- A car/truck? A car/truck?
- A ship? A ship?
2
1
2 119 YES
1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 121 120 HECTARES , IF 95 OR MORE, CIRCLE '950'.
95 OR MORE HECTARES 950 DON'T KNOW 998
1
NO. QUESTIONS AND FILTERS CODE SKIP TO
121 Does this household own any livestock, herds, other farm YES . . . . . . . . . animals, or poultry? NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
122 How many of the following animals does this household own? 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'.
123 Does any member of this household have a bank account? YES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1 NO . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2 137 Please show me where members of your household most OBSERVED 1 . . . . . . . . . . . . . . . . . . . often wash their hands. NOT OBSERVED NOT IN DWELLING/YARD/PLOT . . . . .
2 NOT OBSERVED, STOP 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
OBSERVATIONS