Community Household Questionnaire - Template

	A	B	C
1	Questions	Answer Types	Multiple Choice Answers

2	Location Details/Questions
3	Sub-location	Multiple Choice	Kiamunyeki Murunyu Umoja
4	Village	text
5	Cluster	text
6	Name of cluster leader
7	Are you an Owner or Tenant	boolean	Tenant Owner
8	Plot Number (If Owner)	text
9	How long have you lived here?	number
10	-	boolean	Months Years
11	What is your origin area?	text
12	Bread Winner Questions
13	Who is the breadwinner?	Multiple Choice	Father Mother Other (Specify)
14	If other please specify	text
15	What is the name of breadwinner?	text
16	Age	number
17	Phone Number	number
18	ID Number	number
19	Are you registered to vote?	boolean	Yes No
20	Occupation	text
21	Religion:	Multiple Choice	Christian Muslim Hindu Other (specify)
22	If other please specify	text
23	What is your highest level of education?	Multiple Choice	Primary, Secondary, Tertiary, University, None
24	How much do you spend on average per month for food, clothing, shelter, health, education?	Multiple Choice	< 3000, > 3001 < 6000, > 6001
25	Are you disabled?	boolean	Yes No
26	If yes, specify disability.	Multiple Choice	Blindness, hearing, physical, mental
27	If disability is identified	multiple choice	a. No- no difficulty b. Yes – some difficulty c. Yes – a lot of difficulty d. Cannot do at all
28	Have you had any of the following diseases in the last 6 months?	Multiple Choice	Malaria Waterborne Diseases(Typhoid, Hepatitis,Bilharzia) TB Respiratory Diseases Cholera
29	Have you visited a health facility in the last six months?	boolean	Yes No
30	If yes, which one?	Multiple Choice
31	(If Yes) How long did it take you to reach the health facility?	Multiple Choice
32	Are you covered by NHIF?		Yes No
33	Are you part of any saving scheme?	Multiple choice	sacco chama insurance other(specify)
34	Do you smoke?	boolean	Yes, No
35	If yes, for how long have you been smoking?
36	Do you involve your spouse in decision making in the house?	Multiple Choice	Fully partially not at all
37	Twitter
38	Do they follow your Chief on twitter?	boolean	Yes No
39	Do they follow your Assistant Chief on twitter?	boolean	Yes No
40	Do they follow your Cluster leader on twitter?	boolean	Yes No
41	Do they get tweets from your Chief?	boolean	Yes No
42	Do they get tweets from your Assistant Chief?	boolean	Yes No
43	Do they get tweets from your Cluster leader?	boolean	Yes No
44
45	HOUSEHOLD MEMBER QUESTIONS
46	What is the relation to breadwinner?	Multiple Choice	Spouse, Son, Daughter, Relative (Specify)
47	What is the Gender	Multiple Choice	M, F
48	What is the name of member?	text
49	Age	number
50	Does the child go for ECD	Multiple Choice	Yes, No
51	If Yes, Where do they go?	text
52	Where does the family member go to school?	text
53	Type of Institution	Multiple Choice	Primary, Secondary, University
54	If child is in school, how often have they been absent from school in the	Multiple Choice	Never,0-10 days, 11-20 days, 21-30 days,30+ days
55	Phone Number	number
56	ID Number	number
57	Is the member registered to vote?	boolean	Yes,No
58	Occupation	text
59	Religion:	Multiple Choice	Christian Muslim Hindu Other (specify)
60	If other please specify	text
61	What is your highest level of education?	Multiple Choice	Primary, Secondary, Tertiary, University, None
62	Which of these facilities do they have in school?	Multiple Choice	Running Water Toilet Feeding Program Library Permanent Structured Classes
63	Vocational training: have you participated in Vocational training?	boolean	Yes No
64	Are you disabled?	boolean	Yes,No
65	If yes, specify disability.	Multiple Choice	Blindness, hearing, physical, mental
66	If disability is identified	multiple choice	a. No- no difficulty b. Yes – some difficulty c. Yes – a lot of difficulty d. Cannot do at all
67	If in school, does the school cater for disability identified	boolean	Yes No
68	Has the member had any of the following diseases in the last 6 months?	Multiple Choice	Malaria Waterborne Diseases(Typhoid, Hepatitis,Bilharzia) TB Respiratory Diseases Cholera
69	Has the member visited a health facility in the last six months?	boolean	Yes No
70	If yes, which one?	Multiple Choice
71	(If Yes) How long did it take the member to reach the health facility?	Multiple Choice
72	Is the membered covered by NHIF?		Yes No
73	Twitter
74	Do they follow your Chief on twitter?	boolean	Yes No
75	Do they follow your Assistant Chief on twitter?	boolean	Yes No
76	Do they follow your Cluster leader on twitter?	boolean	Yes No
77	Do they get tweets from your Chief?	boolean	Yes No
78	Do they get tweets from your Assistant Chief?	boolean	Yes No
79	Do they get tweets from your Cluster leader?	boolean	Yes No
80	Do you have any orphans living here?	boolean	Yes No
81	If yes, how many?	number
82	If yes, do you receive assistance to in caring for them	Multiple choice	Gvt, church, family
83	What Kind of assistance do you receive from government?	Multiple Choice	School bursaries? IDP Support Housing subsidies Money Transfers for the elderly
84	Has any member in your household been affected by illicit brew and drugs?	boolean	Yes No
85	How have they been affected?	Multiple Choice	Illness Accident DeathOther (specify)
86	Are you part of any saving scheme?	Multiple choice	sacco chama insurance other(specify)
87	Do you smoke?
88	If yes, for how long have you been smoking?
89	Which of these do you have access to?	Multiple choice	email social media(Twitter, Facebook, etc) whatsapp "mobile phone personal computer cyber cafes at school at the neighbour's place"
90	Property
91	Does this household own any livestock, farm animals or poultry?	boolean	Yes No
92	What livestock do you own?	Multiple choice	Pigs, Poultry, Cows, Goats, Sheep, Donkeys, Fish
93	Are they commercial/ domestic	Multiple choice	Commercial Domestic Both
94	Do you grow your food?	boolean	Yes No
95	If yes, what do you farm/grow?	text
96	Energy, Water and Sanitation
97	What is your main source of energy for lighting?	Multiple choice	Electricity, solar,kerosene
98	What is your main source of energy for cooking?	Multiple choice	Are you a: boolean Tenant Owner Water, Electricity and Sanitation
99	What is your main Source of cooking/drinking water	Multiple choice	River, Water Vendors, rain water, dam, piped water
100	What methods do you use to make your water safe?	Multiple choice	water filters water guard Other purification mechanisms