Questionnaire for the Rapid Assessment of Disability Adults Philippines

Transcription

1 Questionnaire for the Rapid Assessment of Disability Adults Philippines Centre for Eye Research Australia and Nossal Institute for Global Health Questionnaire Cont. Number : _ 1. Identification Household Questionnaire Quezon City/Ligao City 1...Quezon City 2...Ligao City Name of Barangay Name of Purok Household ID number* City Brgy Purok House No. Name of Interviewer Month/Day/Year / / Household Identification (Address) *A different ID number is required for every household. The same ID number is to be reported on the individuals questionnaire. 2. Interview Status 1.Available for interview.go to 3 2.Not available for interview Number of attempts to conduct the interview If not available, please tick one of the following options: 1.Absent 2.Sick 3.Communication Issues If communication issues, please explain 3. Consent 1.Consent given for interview and consent form signed 2.Consent given but refused to sign consent form Why not signed? 4. Interview not completed If interview was not completed, please specify reason 5. Proxy 1.Participant answered for himself/herself.go to H.01 2.Participant s proxy answered 1.All questions Why did the proxy answer all questions? 2.Some questions Why did the proxy answer some questions? 1

2 Questions to be asked to the head of household H.01 How many people are currently living in your household including you, but excluding visitors? H.01a Total number of adults aged 18 years and above H.01b Total number of children aged 0 to 4 years H.01c Total number of children aged 5 to 17 years H.02 How many members of your family are not living in the household, but depend financially on your household? 0.None.Go to H.04 H.02a Total number of adults aged 18 years and above H.02b Total number of children 0 to 4 years H.02c Total number of children 5 to 17 years.go to H.04 H.03 Where do these people live? (Encircle all applicable and indicate the number of people) 1.Their own household 2.Another relative s household 3.Boarding school 4.Centre/Home for persons with disabilities 5.Hospital/clinic 6.Orphanage 7.Street 8.Others, please specify H.04 What is the type of ownership of your lot? (Encircle one answer only) 1.Owned/amortized 2.Rented 3.Renting free with owner s consent 4.Renting free without owner s consent 5.Government owned lot 6.Not applicable 7.Others, please specify H.05 What is the type of ownership of your house? (Encircle one answer only) 1.Owned/amortized 2.Rented 3.Renting free with owner s consent 4.Renting free without owner s consent 5.Government owned house 6.Not applicable 7.Others, please specify_ H.06a Does your household own an agricultural land? 0.No.Go to H.07 1.Yes. Go to H.07 H.06b If YES, what is the total agricultural land area owned by your household? (Indicate unit in hectares/meters) 2

3 H.07 What is the household s main source of drinking water? (Encircle one answer only) 1.Piped water system into dwelling 2.Piped water system into yard/lot 3.Piped water system into public tap 4.Protected well 5.Open dug well 6.Developed spring 7.Undeveloped spring 8.River/Pond/Stream/Lake/Dam 9.Bottled water/refilling station 10 Rain water 11 Tanker truck/peddler 12 Others, please specify H.08 What is the main source of water of your household to wash utensils? (Encircle one answer only) 1.Piped water system into dwelling 2.Piped water system into yard/lot 3.Piped water system into public tap 4.Protected well 5.Open dug well 6.Developed spring 7.Undeveloped spring 8.River/Pond/Stream/Lake/Dam 9.Bottled water/refilling station 10 Rain water 11 Tanker truck/peddler 12 Others, please specify H.09 What type of toilet facility does your household use? (Encircle one answer only) 1.Flush toilet owned 2.Flush toilet shared 3.Close pit latrine 4.Open pit latrine 5.Drop/Hanging latrine 6.No toilet facility/open field/bush 7.Others, please specify H.10 What material is the roof of your house predominantly made of? (Encircle one answer only) 1.Nipa/Cogon/Anahaw (Straw/Thatch) 2.Galvanized iron sheets 3.Ceramic tiles 4.Asbestos 5.Others, please specify H.11 What material are the outer walls of your house predominantly made of? (Encircle one answer only) 1.Nipa/Cogon/Bamboo 2.Wood 3.Galvanized iron/aluminium 4.Cement/Brick/Stone 5.Half cement/brick/stone/and half wood 6.Asbestos 7.Glass 8.Makeshift/salvaged/improvised 9.Others, please specify 3

4 H.12 What material is the floor of your house predominantly made of? (Encircle one answer only) 1.Wood planks 2.Bamboo/Palm 3.Earth/sand 4.Cement 5.Parquet or polished wood 6.Vinyl or Asphalt strips 7.Ceramic tiles 8.Marble 9.Others, please specify H.13 What fuel do you usually use for cooking? (Encircle one answer only) 1.Electricity 2.Kerosene 3.LPG 4.Wood/Charcoal/Sawdust/Coconut husk/rice husk 5.Others, please specify H.14 Does your household own any of the following items that are functioning? (Encircle the applicable codes) Yes, functioning No, not functioning No response/can t say/don t know Doesn t own item H Television H Radio H Refrigerator/Freezer H Sewing machine H Sofa H Washing machine H Personal computer H Electricity H Fan H Air Conditioner H Closet/Wardrobe H Mattress H Landline Telephone H Mobile phone H CD/VCD/DVD player H Bicycle/Pedicab H Motorcycle/Tricycle H Car/Jeep/Van/Multicab H Motorized banca/boat H Tractor H.15a Does your household own any farm animals (Chicken, Pigs, etc.)? 0.No.Go to H.16 1.Yes.Go to H.16 H.15b If YES, How many? (Enter number of animals owned) H.15b.1 Chicken, ducks, etc. H.15b.2 Goats H.15b.3 Pigs H.15b.4 Cows H.15b.5 Carabaos/Buffaloes H.15b.6 Horses H.15b.7 Others, please specify 4

5 H.16 In the last twelve months, how would you classify your household in terms of food consumption? (Read out first four options Encircle one answer only) 1.Did not have sufficient food for the whole year 2.Did not have sufficient food sometimes 3.Just enough food 4.More than enough food 5.Others, please specify Thank you 5