Confidential

HOUSEHOLD QUESTIONAIRE
SOCI0-ECONOMIC SURVEY AND SAFE-WATER AVAILABILITY

INTRODUCTION
Good day/afternoon/evening Sir/Madam. My Name is _______________, currently I am working for Ditjen Cipta Karya, IndII and PT. MTP, JAKARTA to conduct household survey regarding safe-water condition. The questions that we are going to ask are about the primary water source and water quality condition, health condition as well as sanitation environment in your household. All information gathered from the survey will support local government plan on increasing the population access to safe-water. The interview will take about 30 minutes. All information from you will be strictly kept confidential and will not be shared to everyone else. Your participation in this survey is a voluntary based and you may refuse to answer or to continue the interview. We sincerely hope that you can be participating as your opinions are important for us to support the success of this program. Are you willing to participate in this survey? 1. 2. Yes No

IF THE RESPONDENTS AGREES TO BE INTERVIEWED, INTERVIEW CAN BE START. IF RESPONDENTS DISAGREES, END IT AND FIND OTHER RESPONDENT BY DOING ANOTHER SAMPLING.

THE RESULT OF HOUSEHOLD VISIT Interviewer Name : INTERVIEWER VISIT Date/Month/Year Hours Start/Hours Finish CHECKED BY INTERVIEWER Name Date/Month/Year / / / / / / SUPERVISOR DATA ENTRY / / / Interviewer Code : SUPERVISOR VERIFICATION / / /

A. INTRODUCTION OF SITE A01 A02 A03 A04 A05 A06 A07 Province : District/City : Sub District : Village : RW /RT : Household Code: Complete address :

A08 A09 A10

Common mark of house location: Mobile phone no.: HOUSEHOLD CATEGORY: 1. CANDIDATE TO RECEIVE THE PROGRAM 2. CONTROL

B. RESPONDENT IDENTITY Next, we would like to ask your information more detailed B01 B02 B03 Name RESPONDENT GENDER Your position in the household 1. Male 2. Female
1. 2. 3. Head of household Spouse/partner of head of household Others household members

B04 B05

Age Last level of education attained

years old
1. 2. 3. 1. 2. 1. 3. 1. 2. 3. 1. 2. Not school/Primary school not completed PS/MI JHS/MTS Work Not Work Not Married C01 Widow C01 Not school/Primary school not completed PS/MI JHS/MTS Work Not Work 4. 5. SHS/SMK/MA College/ Academy/ University Others (ex:retirees) Married

B06 B07 B08 B09

Working status Marital status Spouse Age Last level of education attained by spouse Working status of spouse

3. 2.

years old
4. 5. SHS/SMK/MA College/ Academy/ University Others (ex:retirees)

B10

3.

C. RESIDENCE CHARACTERISTICS
Next, we would like to ask about your status of your residence that you live in currently. C01 Status of your residence that you live in currently 1. 2. 3. 1. 2. 3. Own property Parent property/other family Rent Ground Wood/Board Plaster/cement 4. 5. Occupy/ official house Others ___________________ Marble/tile/ceramic Others __________________

C02

C03

ENUMERATOR IS ASKED TO CONDUCT OBSERVATION OF THE RESPONDENTS HOUSE CONDITION. TYPE OF THE RESPONDENT RESIDENCE WIDEST FLOOR: What is the type of electric power at your residence

4. 5.

1. 2.

450 VA 900 VA

3.

1300 VA

D. INFORMATION OF HOUSEHOLD MEMBERS

Next, we would like to ask about your household members. The question covers total household members, education status, working status, any physical limitations/barriers.

HOUSEHOLD MEMBERS CATEGORY

TOTAL a

ADULT MIN JHS b

ADULT WORKING c

WITH SPECIAL NEEDS d

D01 D02 D03 D04 D05 D06 D07

Male adult (>18 Years old) Female adult (> 18 Years old) School-aged male (5 - 18 Years old) School-aged female (5 - 18 Years old) Preschool-aged male (<5 Years old) Preschool-aged female (<5 Years old) TOTAL

E. HOUSEHOLD WATER SUPPLY CONDITION

Next, we would like to ask about the main source of water for your household needs such us drinking, cooking, shower, and washing.

INTERVIEWER NOTE: ASK COLOUMN BY COLOUMN

E01 What is the primary water source that your household used for [...] 01. 02. 03. 04. 05. 06. 07. 08. 09. 10. E02 Within 1(one) last month, does your primary water source for [...] usage experience any quality changes such as [...]:
QUESTIONS ARE READ ONE BY ONE

A. Drinking
Bottled water Water vendor Water truck Kiosk for water refill Public/community tap Pump well (jet pump/ hand) Dug well Spring Water from neighbors Others (river/pond/lake/ PAH) 01. 02. 03. 04. 05. 06. 07. 08. 09. 10.

B. Cooking
Bottled water Water vendor Water truck Kiosk for water refill Public/community tap Pump well (jet pump/hand) Dug well Spring Water from neighbors Others (river/pond/lake/ PAH)

C. Washing/bath
01. 02. 03. 04. 05. 06. 07. 08. 09. 10. Bottled water Water vendor Water truck Kiosk for water refill Public/community tap Pump well (jet pump/hand) Dug well Spring Water from neighbors Others (river/pond/lake/ PAH)

PLEASE ANSWER BY CIRCLING ONE CHOICE ONLY

E03 E04

A. Smell B. Tasted differently C. Colored Do you purchase water to [...] How much is the average liters monthly consumption of water purchased for [...] usage
ENUMERATOR HELPS THE RESPONDENT IN CALCULATION. PLEASE NOTE THE UNITS USED IN THE PURCHASING.1

1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No EO6 . litre

1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No EO6 . litre

1. Yes 2. No 1. Yes 2. No 1. Yes 2. No 1. Yes 2. No EO6 . litre

E05

How much does it cost monthly for [...]

ENUMERATOR HELPS THE RESPONDENT IN CALCULATION OF TOTAL WATER PURCHASED BYASKING PRICE PER UNIT.

.
EO8

.
EO8

.
EO8

E06

Is water used for [...] daily available

E07

Is water used for [...] available every time within 1 year?

1. Yes, 24 hours per day 2. No, between 12-24 hours per day 3. No, less than 12 hours per day 1. Yes, 12 months in a year 2. No, only certain months (ex: rainy season)
1.Outside house 2.Inside house E01.B

1. Yes, 24 hours per day 2. No, between 12-24 hours per day 3. No, less than 12 hours per day 1. Yes, 12 months in a year 2. No, only in certain months (ex: rainy season)
1.Outside house 2.Inside house E01.C

1. Yes, 24 hours per day 2. No, between 12 to 24 hours per day 3. No, less than 12 hours per day 1. Yes, 12 months in a year 2. No, only in certain months (ex: rainy season)
1.Outside house 2.Inside house E11

E08 E09

Where is the location of the primary water source that is used for [...] How distance the family members

E04. UNIT OF WATER PURCHASED COMMONLY USED: 1 m = 1000 liters; 1 jerrycan = 20 liters; 1 galon = 18 liters

INTERVIEWER NOTE: ASK COLOUMN BY COLOUMN

travel to get the water from the primary water source by walk (one way)?
E10 How long does it takes by the family members to get the water from the main water source by walking? (This includes queuing and water gathering, round trip)

A. Drinking
. meter

B. Cooking
. meter

C. Washing/bath
. meter

minutes
E01.B

minutes
E01.C

minutes
E11

E11

Name the family members who are in charge to get the water for household needs. A. Adult male (>18 years old) B. C. E. Adult female (> 18 years old) School-aged male (5 - 18 years old) Preschool-aged male (<5 years old)

1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes

2. No 2. No 2. No 2. No 2. No 2. No

D. School-aged female (5 - 18 years old) F. Preschool-aged female (<5 years old) ENUMERATOR NEEDS TO CHECK ANSWER OF D05 DAN D06: 1. IF THERE IS ANY HOUSEHOLD MEMBER UNDER 5 YEARS E13 2. IF THERE IS NO HOUSEHOLD MEMBER UNDER 5 YEARS E14 Within the last 2 months, is there any family members, under 5 years old who ever suffer from [...]? A. Diarrhea B. E14 Itching 1. 2. 3. 4. 5. Generally, how satisfied are you with the existing water supply facilities that currently used?

E12

E13

1. Yes

2. No

1. Yes 2. No Very dissatisfied Dissatisfied Netral Satisfied Very satisfied

F. PARTICIPATION, AWARENESS AND COMMUNITY HYGIENE PRACTISE

Next, we would like to ask about any social activities related to safe-water joined by household members within the last 12 months F01 Within the last 12 month, has there been any meeting in the community to discuss some issues related to safe-water? Who were invited in that meeting? 1. 2. 3. 1. 2. 3. 1. 2. 1. 2. 3. 1. 2. Yes No F07 Do not know F07 Only male household member (ex. husband) Only female household member (ex. wife) Both household member, male and female Yes No F07 Only male household member (ex. Husband) Only female household member (ex. Wife) Both household member, male and female Yes No F07

F02

F03 F04

Did any household member attend the meeting? Name of household member who attended the meeting?

F05

Whether decision related to safe-water was decided in the meeting?

F06

Who was dominant in the meeting in decision making?

F07

Within the last 12 month, has there been any meeting in the community to discuss some issues related to sanitation and hygiene? Who were invited in that meeting?

1. 2. 3. 1. 2. 3. 1. 2. 3. 1. 2.

Male Female Male and female Yes No F13 Do not know F13 Only male household member (ex. Husband) Only female household member (ex.wife) Both household member, male and female Yes No F13

F08

F09

Did any household member attend the meeting?

F10

Name of household member who attended the meeting?

1. 2. 3. 1. 2.

F11

Whether decision related to sanitation and hygiene was decided in the meeting? Who was dominant in the meeting in decision making?

Only male household member (ex. Husband) Only female household member (ex. Wife) Both household member, male and female Yes No F13

F12

INTERVIEWER NOTE: ASK COLOUMN BY COLOUMN

F13 Within the last 6 months, have you ever had/given any information about counselling of [...] Where did you get that information?

A. The benefit of safe-water

1. Male 2. Female 3. Male and female B. The importance of maintaining and protecting safewater source
1. Yes 2. No F13C

C. Good hygiene practice

1. Yes 2. No F13B

1. Yes 2. No F15

F14

1. 2. 3. 4. 5.

TV Radio Newspaper Heath counselling Others _______________

1. 2. 3. 4. 5.

TV Radio Newspaper Health counselling Others _______________

1. 2. 3. 4. 5.

TV Radio Newspaper Health counselling Others ______________

QUESTION F09 AND F10 ARE OPEN QUESTIONS. MAKE NOTES OF ALL RESPONDENT ANSWERS. DONT LEAD RESPONDENT TO A SPESIFIC ANSWER. QUESTION ARE INTENDED TO FIND OUT ABOUT THE RESPONDENT LEVEL OF KNOWLEDGE REGARDING GOOD HYGIENE PRACTISE F15 F16 Can you tell me how you wash your hand? When do you usually wash your hand? WAIT FOR SPONTANIOUS ANSWER, AND DO PROBING ANSWER (ASNWER CAN BE MORE THAN 1) A. After defecation B. After cleaning the babys bottom 1. Yes 1. Yes 2. No 2. No 1. 2. Only use water Using water and soap

C.

Before cooking/preparing food

1. Yes 1. Yes 1. Yes 1. Yes

2. No 2. No 2. No 2. No

D. Before feeding a child E. F. Before eating Others_________________________________

G. HOUSEHOLD INCOME AND ASSET OWNERSHIP

Next, we would like to ask about household income such as wage/salary and other incomes for the last 1 month. G01 How much is the average income of your household per month? (It is a total income from all family member who work, from renting house or else, submissions from family members working outside the city or foreign country, pension fund, etc) Does your household have [...] (QUESTIONS ARE ASKED ONE BY ONE) A. AC B. C. E. F. Washing machine LCD TV Laptop / Computer Mobile phone (HP) post paid 1. 2. 3. 4. 5. 6. < Rp. 500,000 Rp. 500,000 Rp. 1,500,000 Rp. 2,500,000 Rp. 3,500,000 > Rp. 4,500.000 s/d Rp. 1,500,000 s/d Rp. 2,500,000 s/d Rp. 3,500,000 s/d Rp. 4,500,000

G02

1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes 1. Yes

2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No 2. No

D. Refrigerator

G. Motorcycle H. Car I. Land and house (other than the one being occupied)

H. THE DESIRE TO HAVE A PIPED WATER CONNECTION AND WILLINGNESS TO PAY

Next, we would like to ask whether you have a desire to have piped water connection that provide by PDAM. Installation cost for innitial/new connection Rp. ______________ (Get the information from PDAM) H01 If you are able to get the piped water service with good quality (clear, no taste, 1. Yes H04 2. No odorless)? By paying installation cost [...], are you interested to get the piped water connection? Why are you not interested to have piped water connection? 1. I Cannot afford the installation cost 2. I dont have problem with water availability STOP 3. Others, which is: _________________________________ STOP If you are able to pay the installation cost by installment plan or get a discount, are 1. Yes H04 2. No, with reason you interested to get piped water connection? Stated the reason:

H02

H03

 STOP You declare that you are interested to get the piped water connection. To maintain and ensure the continuity of the piped water, PDAM will charge you by monthly bill. The bill will be based on the water volume used in a month and the piped water rate applicable is per cubic meter. H04 H04A If you are able to get the pipe water connection with good quality (clear, no taste, odorless), are you willing to pay the monthly bill? How much money do you pay maximum or allocated for 18,000 liters water 3 consumption or 18 m or the average used of 600 litre per day or water tank in medium sized (600 liters)? (in thousand Rupiah) - STOP
ENUMERATOR NOTE: WE WANT TO HAVE TRULY ANSWERS. TO HELP RESPONDENT IN IMAGINING WATER QUALITY, PLEASE SHOW THE PICTURE CARD. IF NECESSARY, ASK THE RESPONDENT TO RECONSIDER THE ANSWER, SPECIFICALLY BY CALCULATING THE HOUSEHOLD INCOME AND EXPENDITURE FOR THE OTHER NEEDS.

1. 2.

Yes No H04B

Rp.

H04B

If not willing to pay, why? Please mention the reason?

________________________________________________________