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Sample Questionniar

This document contains a survey with questions about socio-demographic data, living conditions, personal lifestyle, current medical problems, and past medical history. It includes questions about the respondent's age, sex, education level, occupation, family situation, housing, smoking and drinking habits, current symptoms of coughing and TB treatment details, pre-existing medical conditions, and BCG vaccination history. The responses are multiple choice or short answer format.

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Jemal Ahmed
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27 views2 pages

Sample Questionniar

This document contains a survey with questions about socio-demographic data, living conditions, personal lifestyle, current medical problems, and past medical history. It includes questions about the respondent's age, sex, education level, occupation, family situation, housing, smoking and drinking habits, current symptoms of coughing and TB treatment details, pre-existing medical conditions, and BCG vaccination history. The responses are multiple choice or short answer format.

Uploaded by

Jemal Ahmed
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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1.

SOCIO-DEMOGRAPHIC DATA

SN. QUESTIONS CHOICES RESPONSE SKIP


0101 How old are you? Write in years

0102 Sex 1. M
2. F
0103 What is your marital status? 1. Married
2. Unmarried
3. Widowed
4. Divorced

0104 What is your educational status? 1. Illiterate


2. Read and write local language
3. Elementary (1-8)
4. Secondary school (9-12)
5. College or more

0105 What do you do for living? 1. Health worker


2. Civil servant other than health
worker:
3. Merchant
4. Student
5. Unemployed
6. Housewife
7. Other (specify) :

2. LIVING CONDITION
0201 Whom are you living with? 1. Family members (parents,
siblings, children, other
relatives)
2. Alone
3. Congregate settings
4. Street life
5. Other (specify) :
0202 Have you ever lived in congregate settings? 1. Yes
2. No
0203 What is the size of the family you are living Write number of persons
with:
0204 What is your average household monthly Write amount in birrs
income?
0205 How many rooms are there in your house?
Write number of rooms
0206 What is the volume of your house? Write the size in m 3 (assist
to make reasonable estimate)
0207 How many windows does your house has? 1. No window To 0209
2. One
3. Two
4. Three
5. More than three
0208 How often does the window at your house 1. Whole day
remain open during the day-time when people 2. Half day
are in the room? 3. 2-3 hours
4. Never
0209 Was/is there any member of the family who 1. Yes
had/has TB disease? 2. No To 0211

0210 When did that person suffered from TB? Write calendar year (EC):

0211 Was/Is there any person in work place who 1. Yes


had/has TB? 2. No To 0301

0212 If the answer to question 16 is yes, when did Write calendar year (EC):
that person suffered from TB?

3. PERSONAL LIFE STYLE


0301 Do you smoke cigarette? 1. Yes
2. No To 0303

0302 If so, how many do you smoke per day? 1. Less than 5
2. 6-10
3. 10-20
4. More than 20

0303 Do you drink alcohol? 1. Yes


2. No To 0401

0304 If so, how often? 1. Daily


2. Twice per week
3. on average once per week
4. on average once per month
5. Rarely

4. CURRENT MEDICAL PROBLEM


0401 How long has it been since you started Write duration in weeks
coughing?
0402 Date of confirmation of diagnosis of TB? Write ( dd/mm/yy) __/__/__

0403 Date of starting Treatment Write (dd/mm/yy) __/__/__

5. PAST MEDICAL HISTORY


0501 Do you have any past chronic illness? 1. Yes
2. No To 0503

0502 If so, do you have any of the following? 1. Diabetes mellitus


(multiple answer possible) 2. Asthma
3. Chronic obstructive pulmonary
diseases
4. Psychiatric problems
5. Other (Specify)
0503 Have you been vaccinated for BCG? (Check 1. Yes
left or right deltoid for BCG scar) 2. No

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