Community Household Questionnaire - Template
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ABC
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QuestionsAnswer TypesMultiple Choice Answers
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Location Details/Questions
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Sub-locationMultiple ChoiceKiamunyeki Murunyu Umoja
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Villagetext
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Clustertext
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Name of cluster leader
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Are you an Owner or TenantbooleanTenant Owner
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Plot Number (If Owner)text
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How long have you lived here?number
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-booleanMonths Years
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What is your origin area?text
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Bread Winner Questions
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Who is the breadwinner?Multiple ChoiceFather Mother Other (Specify)
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If other please specifytext
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What is the name of breadwinner?text
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Agenumber
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Phone Numbernumber
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ID Numbernumber
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Are you registered to vote?booleanYes No
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Occupationtext
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Religion:Multiple ChoiceChristian Muslim Hindu Other (specify)
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If other please specifytext
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What is your highest level of education?Multiple ChoicePrimary, Secondary, Tertiary, University, None
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How much do you spend on average per month for food, clothing, shelter, health, education?Multiple Choice< 3000, > 3001 < 6000, > 6001
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Are you disabled?boolean Yes No
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If yes, specify disability.Multiple ChoiceBlindness, hearing, physical, mental
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If disability is identifiedmultiple choicea. No- no difficulty
b. Yes – some difficulty
c. Yes – a lot of difficulty
d. Cannot do at all
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Have you had any of the following diseases in the last 6 months?Multiple ChoiceMalaria Waterborne Diseases(Typhoid, Hepatitis,Bilharzia) TB Respiratory Diseases Cholera
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Have you visited a health facility in the last six months?booleanYes No
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If yes, which one?Multiple Choice
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(If Yes) How long did it take you to reach the health facility?Multiple Choice
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Are you covered by NHIF?Yes No
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Are you part of any saving scheme?Multiple choicesacco
chama
insurance
other(specify)
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Do you smoke?booleanYes, No
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If yes, for how long have you been smoking?
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Do you involve your spouse in decision making in the house?Multiple ChoiceFully
partially
not at all
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Twitter
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Do they follow your Chief on twitter?booleanYes No
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Do they follow your Assistant Chief on twitter?booleanYes No
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Do they follow your Cluster leader on twitter?booleanYes No
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Do they get tweets from your Chief?booleanYes No
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Do they get tweets from your Assistant Chief?booleanYes No
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Do they get tweets from your Cluster leader?booleanYes No
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HOUSEHOLD MEMBER QUESTIONS
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What is the relation to breadwinner?Multiple ChoiceSpouse, Son, Daughter, Relative (Specify)
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What is the GenderMultiple ChoiceM, F
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What is the name of member?text
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Agenumber
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Does the child go for ECDMultiple ChoiceYes, No
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If Yes, Where do they go?text
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Where does the family member go to school?text
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Type of InstitutionMultiple ChoicePrimary, Secondary, University
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If child is in school, how often have they been absent from school in theMultiple ChoiceNever,0-10 days, 11-20 days, 21-30 days,30+ days
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Phone Numbernumber
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ID Numbernumber
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Is the member registered to vote?booleanYes,No
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Occupationtext
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Religion:Multiple ChoiceChristian Muslim Hindu Other (specify)
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If other please specifytext
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What is your highest level of education?Multiple ChoicePrimary, Secondary, Tertiary, University, None
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Which of these facilities do they have in school?Multiple ChoiceRunning Water Toilet Feeding Program Library Permanent Structured Classes
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Vocational training: have you participated in Vocational training?booleanYes No
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Are you disabled?boolean Yes,No
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If yes, specify disability.Multiple ChoiceBlindness, hearing, physical, mental
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If disability is identifiedmultiple choicea. No- no difficulty
b. Yes – some difficulty
c. Yes – a lot of difficulty
d. Cannot do at all
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If in school, does the school cater for disability identifiedbooleanYes No
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Has the member had any of the following diseases in the last 6 months?Multiple ChoiceMalaria Waterborne Diseases(Typhoid, Hepatitis,Bilharzia) TB Respiratory Diseases Cholera
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Has the member visited a health facility in the last six months?booleanYes No
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If yes, which one?Multiple Choice
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(If Yes) How long did it take the member to reach the health facility?Multiple Choice
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Is the membered covered by NHIF?Yes No
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Twitter
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Do they follow your Chief on twitter?booleanYes No
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Do they follow your Assistant Chief on twitter?booleanYes No
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Do they follow your Cluster leader on twitter?booleanYes No
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Do they get tweets from your Chief?booleanYes No
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Do they get tweets from your Assistant Chief?booleanYes No
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Do they get tweets from your Cluster leader?booleanYes No
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Do you have any orphans living here?booleanYes No
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If yes, how many?number
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If yes, do you receive assistance to in caring for themMultiple choice Gvt, church, family
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What Kind of assistance do you receive from government?
Multiple ChoiceSchool bursaries?
IDP Support
Housing subsidies
Money Transfers for the elderly
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Has any member in your household been affected by illicit brew and drugs?booleanYes No
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How have they been affected?Multiple ChoiceIllness Accident DeathOther (specify)
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Are you part of any saving scheme?Multiple choicesacco
chama
insurance
other(specify)
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Do you smoke?
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If yes, for how long have you been smoking?
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Which of these do you have access to?Multiple choiceemail
social media(Twitter, Facebook, etc)
whatsapp "mobile phone
personal computer
cyber cafes
at school
at the neighbour's place"
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Property
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Does this household own any livestock, farm animals or poultry?booleanYes No
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What livestock do you own?Multiple choicePigs, Poultry, Cows, Goats, Sheep, Donkeys, Fish
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Are they commercial/ domesticMultiple choiceCommercial
Domestic
Both
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Do you grow your food?booleanYes No
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If yes, what do you farm/grow?text
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Energy, Water and Sanitation
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What is your main source of energy for lighting?Multiple choiceElectricity, solar,kerosene
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What is your main source of energy for cooking?Multiple choiceAre you a: boolean Tenant Owner Water, Electricity and Sanitation
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What is your main Source of cooking/drinking waterMultiple choiceRiver, Water Vendors, rain water, dam, piped water
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What methods do you use to make your water safe?Multiple choicewater filters
water guard
Other purification mechanisms
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