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Kidu
Morea
Kari
Cathy
George
DataNova
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Pre-Survey Details
Household ID#
*
Use the Interview ID# of the Head of this house as the Household ID# for this household
Interview ID# (automatic)
*
Geo Stamp:
Geolocation (automatic)
*
Date (automatic)
-
Day
-
Month
Year
Interview Date
Hour Minutes
Date of Birth
*
-
Day
-
Month
Year
*Use estimated DoB if exact DoB is unknown
Gender
*
Male
Female
Official ID available
*
Passport
NID
Driver's License
No ID
Other
Relationship to Head of this Household
*
Head
Wife
Child
Brother
Sister
Cousin
In-Law
Other
Stock Clan
*
Please Select
Araua
Autubua
Botai
Gunina
Kahanamona
Tubukabua
Other...
Community Clan (*select only one):
(1) Araua Idibana 1
(2) Araua Idibana 2
(3) Araua Laurina
(4) Autubua
(5) Avuru Rei
(6) Botai Laurina
(7) Rearea Botai Idibana
(8) Gunina Idibana
(9) Gunina Laurina 1
(10) Gunina Laurina 2
(11) Heri Morea
(12) Igo Konio
(13) Kahanamona
(14) Kahanamona Idibana
(15) Kahanamona Laurina
(16) Kwaradubuna
(17) Rearea
(18) Tubukabua
(19) Vabuori
Other
Place of residency (select more than one if applicable):
Rearea
Port Moresby
Central Province
Another Province
Another Country
Other
1. Personal & Demographic Information
Picture [Mugshot i.e. face pic ONLY]
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of
First Name
*
Middle Name(s)
Surname
*
PNG Mobile Number 1 (8 digits only e.g. 74230123 or 82553499 etc)
If no number, use the Head of Household or parent or guardian's phone number
Mobile Number 2 (8 digits only e.g. 74230123 or 82553499 etc)
Email or Gmail address (if available)
Marital Status
*
Single
Married
Divorced
Denomination
Catholic
United Church
SDA
Baptist
Penticostal
Other
Recreation
Please Select
Football (soccer)
Rugby League
Rugby Union
Netball
Volleyball
Boxing
Athletics
Other
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2. Household & Residential Information
House Type:
*
Permanent
Semi-permanent
Traditional
Makeshift
Other
Home Ownership
*
Own Home
Renting
Relative's home
Company owned property
Parent's home
Other
Number of People in the Household
*
Less than 5
5 < 10
10 < 15
15 , 20
> 20
Picture(s) of House / Residence [5 pictures maximum]
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Access to Electricity
*
Please Select
Yes
No
Sometimes
Electricity Power Supply
PNG Power
Genset
Solar
Hydro
Other Renewable Energy source
Other
Access to Water Supply
*
Public Water Supply
Public Tank
Private Tank (rainwater)
Well Water
Paid Water (water cart)
Type of Toilet Facility
*
Own Septic
Shared Septic
Pit
No Toilet
Toilet in the Sea or mangrove
Other
Is there a handwashing Facility near toilet?
Please Select
Yes
No
Yes/No
How often do you clean your toilet?
Weekly
Monthly
Quarterly
Yearly
Nil
Cooking Fuel Used
Electricity
Wood Stove
Kerosine or Gas
Type of Waste Disposal
Public
No proper waste disposal
Sea
Other
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3. Education / Employment / Health
Education
Highest Level of Education
Please Select
PhD
PhD (Incomplete)
Masters
Masters (Incomplete)
Bachelor's
Incomplete Bachelor's
Secondary School
Secondary School (Incomplete)
Primary School
Early Childhood Education
Current School Attendance
Please Select
Yes
No
Industrial Qualifications & Certifications: Choose all the applicable options (fill in other with the names of the certifications):
Trades Certification
Online Courses
Nursing
ICT
Other
Economic
Employment Status
Please Select
Employed
Unemployed
Self-Employed
Not in Labor Force (child <17 years of age)
(Employed, Unemployed, Self-Employed, Not in Labor Force)
If employed, type of Work
Formal
Informal
SME
Business owner
Other
Formal Income (fortnightly)
Less than K200
K200- K500
K500- K1,000
K1,000- K2,000
K2,000+
Not Applicable
Informal Income (fortnightly)
Less than K200
K200- K500
K500- K1,000
K1,000- K2,000
K2,000+
Not Applicable
Industry of Sector of Employment
Corporate
Government
NGO
Church
Local SME
Other
Agriculture / Fisheries Activities
Subsistance
Commercial Farming / Fishing
Other
What is your MAIN source of food? (chose only 1)
° Mangrove (crabs, shells)
° Sea
° Savannah mammals
° Store food
° Garden crops
° Natural milkfish pond
Other
During extreme and long spell of dry season, where do you source water from?
° Paid water (via watercart)
° Water well (Koki, Rarobada, Bagauda, Iagere)
Other
Which time of the year would there be extreme food scarcity?
Please Select
Quarter 1 (January, February, March)
Quarter 2 (April, May, June)
Quarter 3 (July, August, September)
Quarter 4 (October, November, December)
Do you have a garden?
Please Select
Yes
No
How many gardens do you have?
1 garden
A number of gardens
Other
Location of garden(s):
° Within Buria area (Block 2)
° Within Gunika area (Block)
° Outside Blocks 2 and 3
Other
HEALTH QUESTIONS:
Most regularly accessed health service facility:
Rearea
Papa
Porebada
Hanuabada
Port Moresby
Other
Disability Status: (*leave blank if none)
Visual
Hearing
Physical
Intellectual
No disability
Other
Medical Condition / Status: (*leave blank if none)
TB
Diabetes
Hypertension
Other
Females ONLY - Number of live births
*Leave blank if none
Females ONLY - Number of children currently alive
*Leave blank if none
Age at first birth
Leave blank if never given birth
TECHNOLOGY USAGE
Mobile Phone ownership
Please Select
Yes
No
Own a sim card only but no phone
Internet User
Please Select
Sometimes (few times a week)
Regularly (Every day)
Frequently (Every hour of the day)
Bank Account ownership
Yes
No
Use someone elses
Other
Should be Empty: