DEPARTMENT OF COMMUNITY MEDICINE & PUBLIC HEALTH

PUNJAB MEDICAL COLLEGE/ FAISALABAD MEDICAL UNIVERSITY FAISALABAD

Household Survey Questionnaire

A. Student Information:
1. Name of Student:---------------------------------------------------------------- Roll no:------------------.

2. Date of visit:-----------------------------------: Field Training Batch:--------------------.

B. Household Survey Information:

1. Locality information
1. Name Society/Town/Village:[-------------------------- --------------------------------------------------------------
2. Electoral UC Code:[--------------------------------]
3. Name or Union Council: [-----------------------------------------------------]
4. Name of Tehsil: [----------------------------------------------]
5. Name of District: [---------------------------------------------]
6. Province/ Administrative Area : [--------------------------------------------------------------------------------]

2. Family Head/Key informant

1. 2. 3. 4. 5. 6. 7.
NAME PRESENT AGE AT EDUCATION (YEARS OCCUPATION MONTHLY
AGE MARRIAGE OF SCHOOLING) INCOME
Head of the
Family
Husband
Wife
In case of second marriage record age at first marriage
Note:** Classify occupation under one of the following groups:
Farmer, Laborer, Businessman, Employee Govt)./ Private), No-job

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 3. Detail of Other Family Members
1. 2. 3. 4. 5. 6. 7.
NAME AGE SEX RELATIONSHIP EDUCATION OCCUPATION MONTHLY
WITH THE HEAD INCOME
OF FAMILY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Note:** Classify occupation under one of the following groups:
Farmer, Laborer, Businessman, Employee (Govt)./ Private), Housewife, Student, None
8. Family Members: : Male: [----------------]- Females: [----------------]Total: [---------------]
9. Total number of working family members:-------------------
10. Total Family Income in PKR [Rs.----------------------------------]
11. Family Income per capita in PKR : [Rs----------------------------]

4. Vaccination Status of Children

12. Vaccination status of children up to “2” years of age in family (if applicable)
13.

14.

15.

16.

17.

18.

19.

MEASLES 20.

21.
S.
(Pneumoc
PENTA

+HBV+

ENTRY
POLIO
occal)

(OPV)

No
CARD
(DPT

HiB)
BCG
AGE

PCV
SEX
NAME

1. I II III I II III 0 I II III I II Yes/No

2.
3.
4.
5.
6.
7.

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 5. Births and Deaths
22. Live Birth Last Year: (1st January -------------to 31st December --------------) [ Yes NO] Male [------] Female:[-------]
23. Death in Last Year:(1st January -------------to 31st December --------------) [ Yes NO] Male [------] Female:[-------]
(Cause of death if known: [------------------------------------------------------------------------------------------------------------------------------------------------]

6. Condition of the House

24. Number of living rooms other than Kitchen: [-----------]
25. Construction quality of the House: [ Kicha/Mud Pakka/Brick  Mix Mud/Bricks  Others Specify [----------------
---------------------------------------------------]
26. Animal in the house:  Present within the house  Separate side of the house  Not present
27. If animal present  Domestic animals cattle if yes numbers[------------]  Pets if yes number [------------]

7. Amenities within the house

28. Toilet Facilities within the dwelling: [ Yes NO]

29. If yes: [ Conservancy WC pit latrine  Flush attached Septic tank  Flush in water carriage system  Using
field  Others Specify: [--------------------------------------------------------------------------------------------------]
30. Water sources within the dwelling: [ Yes NO]
31. If yes: [ Piped community supply Motorized pump  Hand pump  Well  Surface reservoir  Others
Specify: [--------------------------------------------------------------------------------------------------]
32. Gas supply within the dwelling: [ Yes NO]
33. If No the alternate source of energy for cooking: [ Wood  Kerosene  Others Specify: [-------------------------------
-------------------------------------------------------------------]
34. Electricity supply within the dwelling: [ Yes NO]

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 8. Service Utilization

35. Preferences of using available health facilities (More than one responses are possible
Government  CHW  BHU  RHC THQ DHQ Teaching Others
Facilities Hospital Hospital Hospital specify
Private Quacks Hakim Homeopath Qualified Private Private Others
Facilities GP Midwifery Hospital specify

Specify Government if others:[-------------------------------------------------------------------------------------------------]

Specify Private if others:[-------------------------------------------------------------------------------------------------]

36. Reasons for not utilizing Government Health facility (if available) please  the relevant box more than one
responses are possible
Unsatisfactory care Insufficient care
Costly Distant
No information
Any other reason (Specify) [--------------------------------------------------------------------------------------------------------]