Questionnaire - Measurement, Learning & Evaluation Project

OFFICE USE ONLY: QUESTIONNAIRE NO: [__|__|__|__|__|__|__|__||__|__](cluster code 4 digits + HH number 3 digits + household division number + Respondent line number 2 digits)Questions and filtersFOLLOW-UP CONTACTSCoding categoriesCLUSTER NUMBER……………………………………………………………………………………..(City code + Cluster number)BASELINE HOUSEHOLD NUMBER……………………………………………………………………..HOUSEHOLD DIVISION NUMBER………………………………………………………………………………..(Same HH=0, Household divided/1 st new household =1, Household divided/2 nd new household =2, etc.)BASELINE LINE NUMBER OF WOMAN ………………………………………………………………..NAME OF ELIGIBLE WOMAN/ RESPONDENT ___________________________________________________NAME OF HOUSEHOLD HEAD ________________________________________________________________ADDRESS OF THE HOUSEHOLD________________________________________________________________________________________________________________________________________________________As I mentioned earlier, you have been selected to participate in this exercise based on your participation in the urban health study about one and ahalf years ago. We will also be back in about two years to update your contact information again. For this reason, I will be asking for the contactinformation of people that maybe able to tell us where you and your household are in case you move. Remember you are free to skip any questionsthat you are uncomfortable providing answers to. This information will be kept separate from your responses in a locked cabinet in a secured roomwhere only the primary researcher can access.Kamar yadda nace daga farko, zamu dawo muga yaya kike ciki nan da shekara biyu, kuma mu kara dawo wa bayan wasu shekara biyu kuma ,domin muga ko wani abu ya canza game da bayanai akan kiwon lafiya . A wannan dalili, zan yi tambaya akan mutanen da za mu nema ko da kinbar nan da zama, wadanda zasu iya fadan inda kike a shekara biyu da kuma shekara hudu nan gaba. Wannan bayanan za a boye a wani kabod akulle, dabam da sauran amsoshin da kika bada inda sai masu Bincike ne zasu samu shiga. . Ki tuna kina da ‘yancin ki tsallake tambayar da batakwanta miki ba.Q1005What other names are you commonlyknown by?_______________________________________________________Q1006Q1007Q1008Wadanne sunayen aka fi sanin kidasu?Do you have access to a cell phone?Kina da wayar hannu ko tarhon gida?If yes, could you please share with mea cell phone number?In kina da ita, ko zaki iya bani lamba?Could you also please share with me asecond cell phone number forcontacting you?YES…………………..1NO…………………….2 skip to 1009PRIMARY CELL NUMBER [ __|__|___|___|___|___|___|___|___|___|___|SECONDARY CELL NUMBER: [__|___|___|___|___|___|___|___|___|___|___|Q1009Zaki iya bani wata lamba?Does your family/household have anyplans to move in the next two years?YES, _______________________________________Q1010Shin ko iyalin ki na da niyar barin nanwajen, nan da shekaru biyu?IF YES, where do you plan to move to?IF YES, ina kuke da niyar komawa?IF RESPONDENT IS NOT HH HEAD:What is the name and cell phonenumber (if possible) of the head of thishousehold?Menene sunan maigidan wannangidan da kuma lambar wayar hannunsa/ta (in da akwai)____________________________________________...1(SPECIFY)NO PLANS TO MOVE………………………………….…….2NAME: _________________________CELL NUMBER: [ ___|___|___|___|___|___|___|___|___|___|___|45