Questionnaire A: Household survey
PART I
District |
____________________________________________________________ |
| |
|
RC |
4 |
____________________________________________________________ |
RC |
3 |
____________________________________________________________ |
RC |
2 |
____________________________________________________________ |
RC |
1 |
____________________________________________________________ |
Household number |
| |
|
____________________________________________________________ |
| |
|
|
Respondent’s name |
_________________________________________________ |
Sex M/F Age ______
Education level |
___________________Occupation____________________ |
Name of supervisor |
_________________________________________________ |
Name of interviewer |
_________________________________________________ |
Date of interview |
_________________________________________________ |
Date of check back |
_________________________________________________ |
1. |
Name of household head________________________________ |
2. |
What is his/her principal source of income? |
| |
0. Unemployed |
| |
1. Civil servant (employed by government) |
| |
2. Employed by a private firm (bank, etc.) |
| |
3. Self-employed/business |
| |
4. Farming/fishing |
| |
5. Others specify_______________________________________ |
3. |
Education level reached by household head (specify) |
| |
________________________________________________________________ |
4. Number of members in the household ________
5. Who was the last person to get an injection in this household? (Which household member?)
a) |
Name |
_______________________ |
| |
Age: |
1. 0-4 years |
| |
|
2. 5-14 years |
| |
|
3. 15 and above |
| |
Sex: |
1. Male |
| |
|
2. Female |
6. When (time) was this injection received?_______________
7. For what reason was the injection given?
1. |
Therapeutic |
2. |
Drip (infusion) |
3. |
Contraception |
4. |
Immunization |
8. If it was therapy, what symptoms were being treated? (Please note down the symptoms in local terms)
_________________________________________________________________________
_________________________________________________________________________
9. What medicine was injected? (use local term)
_________________________________________________________________________
_________________________________________________________________________
10. Where was the injection provided? (Use local categorization)
_________________________________________________________________________
11. Who provided the injection?
_________________________________________________________________________
12. Do you have any kind of relationship with the injection provider?
13. If yes, what is the nature of relationship?
1. |
Parent |
2. |
Relative |
3. |
Friend |
4. |
Neighbour |
5. |
Other________________________ |
EQUIPMENT AT HOME
14. Do you keep needles and syringes in your home?
15. If yes, where did you obtain them?
_________________________________________________________________________
16. Do you keep injectables?
17. If yes, what type of injectables do you have?
1. |
Chloroquine |
2. |
PPF |
3. |
Others______________ |
18. Where did you obtain the injectables (1. Yes 2. No)
1. |
Government facility |
2. |
Non-governmental facility |
3. |
Private clinic |
4. |
Pharmacy |
5. |
Drug shop |
6. |
Shop or market place |
7. |
Drug pedlar or hawker |
8. |
Friend, relative or neighbour |
COMPLICATIONS
19. Has any member of family ever had any complications with injections?
20. If yes, what kind of injection complications (1. Yes 2. No)
1. Abscess
2. Allergy
3. Lameness
21. From where was that injection obtained? (find out the local categorization of facilities)
1. Governmental hospital
2. Government HC
3. Non-governmental HC
4. Private clinic
5. Non-formal facility
6. At home
7. Others (specify)
_________________________________________________________________________
22. Who provided that injection?
_________________________________________________________________________
23. What do you think was the cause of the complication?
1. Provider
2. Bad injectable
3. Bad equipment
4. I do not know
5. Others specify
_________________________________________________________________________
HYPOTHETICAL TRACER CONDITIONS
24. What treatment should be given for the following illnesses? Please fill in Table I.
Table I: Treatment form for tracer conditions based on hypothetical questions
Tracer Condition |
Inject. Only |
Inject. &Oral |
Oral |
Herbal Med. |
Non-Medicin. |
Nothing |
Cough & cold |
|
|
|
|
|
|
Diarrhoea |
|
|
|
|
|
|
Intestinal worms |
|
|
|
|
|
|
Vomiting |
|
|
|
|
|
|
Fever/rise in body temperature |
|
|
|
|
|
|
1. Yes
2. No
PART II: TWO WEEK RECALL PERIOD
(PLEASE NOTE IF THERE IS CHANGE IN THE RESPONDENT)
1. Has anyone in this home been sick during the last two weeks?
1. Yes
2. No
2. In the last two weeks has anyone in this home received any form of injection? (1. Yes 2. No)
1.Therapeutic
2. Immunization
3. Drip (infusion)
4. Contraception
5.None
3. If it was a therapeutic injection then fill in Table II.
4. If it was an immunization then fill in Table III.
Table II: Sickness and treatment in two week period
Name |
Age |
Sex |
Symptoms |
Tracer condition |
Treatment (form) |
No. of inject. |
Medicine (local term) |
Source cost |
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
| |
|
|
|
|
|
|
|
|
Table III: Immunization record
Name |
Sex |
Age |
No. of injections |
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|
| |
|
|
|