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IOM - Assessment on the Psychosocial Needs of Haitians Affected ...

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Annex IV: Study Questi<strong>on</strong>naire<br />

A. Questi<strong>on</strong>naire for Households<br />

IDENTIFICATION PLACE OF ORIGIN<br />

Department<br />

Neighborhood/site<br />

Commune<br />

Place (village/ town)<br />

Name <strong>of</strong> <strong>the</strong> camp<br />

Name <strong>of</strong> interviewee<br />

Organizati<strong>on</strong><br />

Interviewer status<br />

Date:<br />

Time start:<br />

Time finish:<br />

households<br />

LIVIN<br />

LIVING CONDITIONS<br />

1. What kind <strong>of</strong> housing do you have?<br />

2. Are you sharing your housing with o<strong>the</strong>rs?<br />

3. Does <strong>the</strong> family face a threat <strong>of</strong> evicti<strong>on</strong> at any moment?<br />

4. Does <strong>the</strong> family have any restricti<strong>on</strong> <strong>on</strong> <strong>the</strong> freedom <strong>of</strong> movement in your current residence?<br />

5. How much do you pay for <strong>the</strong> rent per m<strong>on</strong>th?<br />

6. How many rooms <strong>the</strong>re are in <strong>the</strong> dwelling?<br />

7. How many <strong>of</strong> <strong>the</strong>se are bedrooms?(<strong>on</strong>ly if applicable)<br />

8. Do you think children have a safe place to play?<br />

9. Age and gender<br />

HOUSEHOLD LIST<br />

10. The date <strong>of</strong> arrival to <strong>the</strong> current place <strong>of</strong> habitati<strong>on</strong><br />

11. What is <strong>the</strong> resp<strong>on</strong>dent’s relati<strong>on</strong>ship with <strong>the</strong> head <strong>of</strong> <strong>the</strong> house<br />

12. Have you lost any member <strong>of</strong> your family due to <strong>the</strong> earthquake?<br />

13. Which educati<strong>on</strong>al level have you accomplished?<br />

53

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