DEPARTMENT OF COMMUNITY MEDICINE PUBLIC HEALTH

PUNJAB MEDICAL COLLEGE/ FAISALABAD MEDICAL UNIVERSITY FAISALABAD

Household Survey Questionnaire

A. Student Information:
1. Name of Student: SARIA ASHRAF Roll no: 168

2. Date of visit: 15 sep 2020 Field Training Batch: B-4

B. Household Survey Information:

1. Locality information
1. Name Society/Town/Village: Basirpur
2. Electoral UC Code:[ 06]

2. Name or Union Council: [MC BASIR PUR ]

3. Name of Tehsil: [ Depalpur ]

4. Name of District: [ Okara ]

5. Province/ Administrative Area : [ Punjab]

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 Muhammad Alam 27 Single middle employee 9000
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

1
 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. Kalsoom bibi 56 Female Mother Illiterate No zero
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
1. Family Members: : Male: [1]- Females: [1]Total: [2]
2. Total number of working family members: 1
3. Total Family Income in PKR [Rs9000]
4. Family Income per capita in PKR : [Rs4500]

4. Vaccination Status of Children

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

CARD ENTRY
MEASLES
POLIO (OPV)
+HBV+ HiB) PENTA (DPT
BCG
NAME

(Pneumoc occal) PCV

No
AGE

SEX

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

2.
3.
4.
5.
6.
7.
 5. Births and Deaths
6. Live Birth Last Year: (1st January -------------to 31st December --------------) [NO]
7. Death in Last Year:(1st January -------------to 31st December --------------) [NO]
(Cause of death if known: []

6. Condition of the House

8. Number of living rooms other than Kitchen: [ 2]
9. Construction quality of the House: [Kacha/mud]
10. Animal in the house:  Not present
11. If animal present  Domestic animals cattle if yes numbers[ ]  Pets if yes number [ ] Not present

7. Amenities within the house

12. Toilet Facilities within the dwelling: [ Yes]

13. If yes: [ conservancy]
14. Water sources within the dwelling: [ Yes]
15. If yes: [Motorized pump ]
16. Gas supply within the dwelling: [ Yes]
17. If No the alternate source of energy for cooking: [ Wood  Kerosene  Others Specify: [
]
18. Electricity supply within the dwelling: [ Yes ]
 8. Service Utilization

19. 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  Priva  Others
Facilities BP Midwifery te specify
Hospital

Specify Government if others:[ ]

Specify Government if others:[ ]

20. 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) [ ]