8/13/2019 (04) PKK(CF)

1/17

EDITOR:__________________________CONFIDENTIAL

INTERVIEWER:______________________

INDONESIANFAMILYLIFESURVEY2000COMMUNITYANDFACILITYSURVEY

DESA/KELURAHANWOMENSGROUP(PKK)

SECTIONS: LK, KR, I, J, PM, KSR,CP

COMMID00

NAMEOF DESA/KELURAHAN : _____________________________________

INTEVIEWBOOKPKK

INTERVIEWI INTERVIEWII INTERVIEWIII Interviewlanguagecode:

DATE:/

DAY/MONTH

/

DAY/MONTH

/

DAY/MONTH

CK1. Interview was entirely/mostly conducted in

what language?

00. Indonesian

01. Javanese

02. Sundanese

03. Balinese04. Batak

05. Bugis

06. Chinese07. Maduranese

08. Sasak

09. Minang10. Banjar

11. Bima

12. Makassar

13. Nias

14. Palembang

15. Sumbawa

16. Toraja17. Lahat

18. Other South Sumat

19. Betawi20. Lampung

96. No other

91. Other____________

TIMEBEGIN:/

HOUR/MINUTE

/

HOUR/MINUTE

/

HOUR/MINUTE Other___________________

TIMEFINISHED:/

HOUR/MINUTE

/

HOUR/MINUTE

/

HOUR/MINUTE

CK2.Other language used (if any):

INTERVIEWRESULTS:

Other___________________

INTERVIEWRESULTSCODE FP5. EDITEDSTATUSBYEDITOR FP6. MONITORINGBYLOCALSUPERVISOR FP7. DATAENTRYSTATUS

PKK BOOKPKK- 1 COM1/18/2003 04:11:00 AM

8/13/2019 (04) PKK(CF)

2/17

1. Completed

2. Partially completed___________________________

4. Refused

1. Edited, no correcton necessary

2. Edited and corrected

3. Edited, but not corrected

4. Not edited,___________________________

Yes No

a. Observed....... .................. ..... 1 3

b. Edited........ .................. ......... 1 3

1. Entered, no correction necessary

2. Entered and corrected

3. Entered, but not corrected________

PKK BOOKPKK- 2 COM1/18/2003 04:11:00 AM

8/13/2019 (04) PKK(CF)

3/17

SECTIONLK: CONTROLSHEET

SAMPLINGINFORMATION CODE

LK01. Province_____________________________________

LK02. Kabupaten/Kotamadya_____________________

LK03. Kecamatan ___________________________________

LK04. Village/Township ______________________________

LK05. Region : 1. Urban 2. Rural

SUPERVISION CODE

LK15. Name of Interviewer : _______________

LK16. Name of Editor : ____________________________________

LK17. Name of Local Supervisor : ____________________________

LK18. Name of Assistant Field Coordinator: ____________________

LK19. Name of Field Coordinator : ___________________________

PKK BOOKPKK- 3 COM

8/13/2019 (04) PKK(CF)

4/17

SECTIONKR:IDENTITYOFRESPONDENT

(KRTYPE) RespondentA RespondentB RespondentC

KR01. Name of respondent_____________________________________ _____________________________________ __________________________________

KR02. AgeYears Years Years

KR03. Position in Village/Township PKK1 2 3 4 __________________ 1 2 3 4 __________________ 1 2 3 4 __________________

KR04. Length of tenure in position

Years

Years

Years

KR05. Highest level of education attended 01 02 03 04 05 06 60 61 62 63

11 12 13 14 72 73 90 98 10

01 02 03 04 05 06 60 61 62 63

11 12 13 14 72 73 90 98 10

01 02 03 04 05 06 60 61 62

11 12 13 14 72 73 90 98 1

KR06. Highest class/grade of education completed00 01 02 03 04 05 06 07 96 98 00 01 02 03 04 05 06 07 96 98 00 01 02 03 04 05 06 07 96

KR07. Length of time residing in this village/townshipYears Years Years

(KRTYPE) RespondentD RespondentE RespondentF

KR01. Name of respondent_____________________________________ _____________________________________ __________________________________

KR02. AgeYears Years Years

KR03. Position in Village/Township PKK1 2 3 4 __________________ 1 2 3 4 __________________ 1 2 3 4 __________________

KR04. Length of tenure in positionYears Years Years

KR05. Highest level of education attended 01 02 03 04 05 06 60 61 62 63

11 12 13 14 72 73 90 98 10

01 02 03 04 05 06 60 61 62 63

11 12 13 14 72 73 90 98 10

01 02 03 04 05 06 60 61 62

11 12 13 14 72 73 90 98 1

KR06. Highest class/grade of education completed00 01 02 03 04 05 06 07 96 98 00 01 02 03 04 05 06 07 96 98 00 01 02 03 04 05 06 07 96

KR07. Length of time residing in this village/townshipYears Years Years

CodeKR03:

1. Head of PKK

2. Organizer of PKK

3. Cadre of PKK

4. Other, mention ___________________

CodeKR06:

Never completed class/grade 1............... 00

1 .............................................................. 01

2 ............................................................. 02

3 .............................................................. 034 .............................................................. 04

5 .............................................................. 05

6 .............................................................. 06Graduated ............................................... 07

CodeKR05:

No school............................................. 01

Elementary School (SD) ..................... 02Junior High School General............. 03

Junior High School - Vocational.......... 04

Senior High School - General.............. 05

Senior High School - Vocational.......... 06

University S1 (Bachelor).......................61

University S2 (Masters)........................ 62University S3 (Doctorate)......................63Kejar Paket A (Adult Educ. A)...............11

Kejar Paket B (Adult Educ. B)...............12

Open University.................................... 13Islamic School (Pesantren)...................14

Islamic Junior/Senior High School

(Madrasah Tsanawiyah)....................Kindergarten.........................................DONT KNOW......................................

Other, mention_____________________

PKK_KR BOOKPKK- 4 COM

8/13/2019 (04) PKK(CF)

5/17

SECTIONKR:IDENTITYOFRESPONDENTNo school................................................. 96

DONT KNOW.......................................... 98D1, D2, D3 (Junior College)................ 60 Islamic Elementary School

(Madrasah Ibtidaiyah).........................72

PKK_KR BOOKPKK- 5 COM

8/13/2019 (04) PKK(CF)

6/17

SECTIONI: HISTORYOFTHEPRESENCEOFSCHOOLS

Now,wewouldliketo askaboutthehistoryof thepresenceof educationfacilitiesin thisvillage.

A. ELEMENTARYSCHOOL B. JUNIORHIGHSCHOOL C. SENIORHIGHSCHOOL

I11. When was the first [] open in this

village/township or the neighboring

village/township?

1. I13 THISCOLUMN8. DONT KNOW

1. I13 THISCOLUMN8. DONT KNOW

1. I13 THISCOLUMN8. DONT KNOW

I12. Approximately how many years agohas the first [] open in this

village/township or the neighboring

village/township?

years................................... 1

DONT KNOW.................................... 8

years................................... 1

DONT KNOW.................................... 8

years................................... 1

DONT KNOW.................................... 8

I13. With regards to the [] available to

the community in this

village/township, how many [] can

be used by the people from this

village/township?

facilities............................... 1

DONT KNOW.................................... 8

facilities............................... 1

DONT KNOW.................................... 8

facilities............................... 1

DONT KNOW.................................... 8

I14. What are the names of the []? 1._________________________________________

2._________________________________________

3._________________________________________

4._________________________________________

5._________________________________________

6._________________________________________

7._________________________________________

8._________________________________________

9._________________________________________

10.________________________________________

11.________________________________________

12.________________________________________

13.________________________________________

14.________________________________________

I11 NEXTCOLUMN

1._________________________________________

2._________________________________________

3._________________________________________

4._________________________________________

5._________________________________________

6._________________________________________

7._________________________________________

8._________________________________________

9._________________________________________

10.________________________________________

11.________________________________________

12.________________________________________

13.________________________________________

14.________________________________________

I11 NEXTCOLUMN

1.___________________________________

2.___________________________________

3.___________________________________

4.___________________________________

5.___________________________________

6.___________________________________

7.___________________________________

8.___________________________________

9.___________________________________

10.__________________________________

11.__________________________________

12.__________________________________

13.__________________________________

14.__________________________________

RESPONDI. INTERVIEWERNOTE:

PKK,PKK_I BOOKPKK- 6 COM

8/13/2019 (04) PKK(CF)

7/17

SECTIONI: HISTORYOFTHEPRESENCEOFSCHOOLS

CIRCLETHELETTERTHATCORRESPONDSTOTHERESPONDENTTHATANSWEREDSECTIONI A B C D E F

PKK,PKK_I BOOKPKK- 7 COM

8/13/2019 (04) PKK(CF)

8/17

SECTIONJ: HISTORYOFTHEPRESENCEOFHEALTHFACILITIES

Now,wewouldliketo askabouthistoryof theexistenceof healthfacilitiesin thisvillage.

J10a. Is there a Village Midwife (Bidan

Desa) located in this village?

Yes...................................................1J10b

No..................................................... 3

J10a1. Has there ever been a village midwife

in this village?No..................................................... 3J11

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

J10a2. When did the village midwife leave

this village?1./

Month Year

8. DONT KNOW

J10cJ10b. How many village midwives are

located in this village?1. people

8. DONT KNOW

J10c. In what year did the first village

midwife begin to practice in this

village?

Year..........................1J10e

DONT KNOW..................................8

J10d. How many years has the village

midwife practiced in this village? Years.................................. 1

DONT KNOW..................................8

J10e. What type of support does/did the

village midwife (the first one) receive

from the local people or the village

office?

NONE...............................................A

Housing............................................B

Food.................................................C

A place to practice............................D

Salary/cash...................................... F

Other,________________________E

J19. In this village is there a Delivery Post

(Pos Bersalin Desa/Polindes)?No..................................................... 3 J11

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

J19a. In what year was the first Polindes

established in this village?Year ........................1J19c

DONT KNOW..................................8

J19b. How many years has the Polindes

operated in this village? years..................................1

DONT KNOW..................................8J19c. How many beds does the Polindes

have? beds................................... 1

DONT KNOW..................................8

J11. How many Health Posts (Posyandu)

exist in this village? ............................................1

DONT KNOW..................................8

PKK BOOKPKK- 8 COM

J13. How many times have staff from

Health Centers (Puskesmas) visited

the Posyandu in the last year?

times.................................... 1

DONT KNOW......................................... 8

J13a. In comparison to the previous years,

have visits in the past 12 months from

the Puskesmas staff changed?

Increased................................................. 1

Decreased...............................................2

No change...............................................3

DONT KNOW......................................... 8

J16. How many Family Planning Assistants

(PPKBD) are located in this village? PPKBD

b. sub PPKBD

J18. In the last year, how many times has a

Family Planning Field Worker (PLKB)

come to this village?

times..................................... 1

DONT KNOW......................................... 8

J18a. In comparison to the previous years,

have the number of visits in the past

12 months by PPKBD changed?

Increased................................................. 1

Decreased...............................................2

No change...............................................3

DONT KNOW......................................... 8

J20. Is there a Medicine Post (Pos Obat

Desa) in this village?No............................................................3

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

J24. Since 1995, have there ever been any

mass immunization/vaccination for the

people in the village?

No............................................................3

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

8/13/2019 (04) PKK(CF)

9/17

SECTIONJ: HISTORYOFTHEPRESENCEOFHEALTHFACILITIES

PKK BOOKPKK- 9 COM

J25.

In what year were mass immunization/vaccination and what were the types of mass immunization/vaccination conducted since 1995?

JA25A. YEAR JA25B. Types of mass immunization/vaccination.

[SEECODEJ.25,CIRCLETHEAPPROPRIATEANSWERCODE,THERECANBEMORETHANONEANSWER]CodeJ25:

1.

A1 A2 B C D E F G __________________________________ A1. Measles

A2. Smallpox

B. BCG

C. Polio

D. DPT

E. Tetanus Toxoid

F. Hepatit is B

G. Other, _________________

2.

A1 A2 B C D E F G __________________________________

3.

A1 A2 B C D E F G __________________________________

4.

A1 A2 B C D E F G __________________________________

5.

A1 A2 B C D E F G __________________________________

6.

A1 A2 B C D E F G __________________________________

8/13/2019 (04) PKK(CF)

10/17

SECTIONJ: HISTORYOFTHEPRESENCEOFHEALTHFACILITIES

PKK BOOKPKK- 10 COM

8/13/2019 (04) PKK(CF)

11/17

SECTIONJ: HISTORYOFTHEPRESENCEOFHEALTHFACILITIES

Aa. IntegratedCommunityHealth

Post(Posyandu)

A. HealthCenters(Puskesmas)

andHealthSub-centers

(PuskesmasPembantu/Pustu)

B. Privatehealthpractitionersuch

as doctors,clinics,medical

posts,maternityclinics,

nurses,midwives,medical

assistants,andother

paramedicalworkers

C. Traditionalhealthworkers,

suchas midwives,Chinese

healer(sinshe),shaman,etc.

D. Publicor privatehospit

J26. With regards to the []

available to the community

in this village/township, how

many [] can be used bythe people from this

village/township?

1. facilities

8. DONT KNOW

1. facilities

8. DONT KNOW

1. facilities

8. DONT KNOW

1. facilities

8. DONT KNOW

1. facilities

8. DONT KNOW

J27. What are the names of the

facilities?

1._______________________

2._______________________

3._______________________

4._______________________

5._______________________

6._______________________

7._______________________

8._______________________

9._______________________

10.______________________

11.______________________

12.______________________

13.______________________

14.______________________

J26COLUMNA

1._______________________

2._______________________

3._______________________

4._______________________

5._______________________

6._______________________

7._______________________

8._______________________

9._______________________

10.______________________

11.______________________

12.______________________

13.______________________

14.______________________

J26COLUMNB

1._______________________

2._______________________

3._______________________

4._______________________

5._______________________

6._______________________

7._______________________

8._______________________

9._______________________

10.______________________

11.______________________

12.______________________

13.______________________

14.______________________

J26COLUMNC

1._______________________

2._______________________

3._______________________

4._______________________

5._______________________

6._______________________

7._______________________

8._______________________

9._______________________

10.______________________

11.______________________

12.______________________

13.______________________

14.______________________

J26COLUMND

1.___________________

2.___________________

3.___________________

4.___________________

5.___________________

6.___________________

7.___________________

8.___________________

9.___________________

10.__________________

11.__________________

12.__________________

13.__________________

14.__________________

RESPONDJ. INTERVIEWERNOTE:

CIRCLETHELETTERTHATCORRESPONDSTOTHERESPONDENTTHATANSWEREDSECTIONJA B C D E F G H I J K L

PKK BOOKPKK- 11 COM

8/13/2019 (04) PKK(CF)

12/17

SECTIONPM:CITIZENPARTICIPATION

Now,wewouldlike to askaboutpeople'sprograms/activitiesin this village/kelurahan

(PMTYPE) PM02. PM03a. PM03b. PM04.

COMMUNITYPROGRAMSOR

ACTIVITIES

(THEHIGHESTLEVELIS THEVILLAGE)

In this village is [] program

conducted?1. It is presentlyconductedona routinebasis.

2. It hasbeenconducted,butpresentlyit is not

conductedin a routinemanner.

3. It hasneverbeenconducted

In what year was the []

program began to be conducted

in this village/township?

In what year was the []

program ended in this

village/township?

Approximately how many

people from this community

are members/usersof this

[] program?

1. Save and Borrow group 3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

2. Village cooperatives 3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

3. Pharmacy Garden 3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

5. Child Development Group

(Bina Keluarga Balita)3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended8. DONT KNOW

1. ,

8. DONT KNOW

6. Adolescents Group (Bina

Keluarga Remaja)3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

7. Senior Citizens Group

(Program Lansia)3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

8. Youth Group (Karang

Taruna)3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

SECTIONPM BOOKPKK- 12 COM

8/13/2019 (04) PKK(CF)

13/17

SECTIONPM:CITIZENPARTICIPATION

9. Health Fund (Dana Sehat) 3 1

2

1. Year

8. DONT KNOW

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

11. Ten Household Program

(Dasa Wisma)3 1

2

1. Year

3. Program has not ended

8. DONT KNOW

1. ,

8. DONT KNOW

SECTIONPM BOOKPKK- 13 COM

8/13/2019 (04) PKK(CF)

14/17

SECTIONPM:CITIZENPARTICIPATION

Now,wewouldlike to knowaboutassistancereceivedby thecommunityin thisvillageeitherfromgovernmentor non-governmentorganizationsoverthelast6 months.

KSR01. KSR02. KSR03. KSR06.

TYPEOFASSISTANCE

(KSR1TYPE)

In the last 12 months were there any programs by local

government or community organizations in your community to

distribute []?

What was the

source of this

assistance []?

In the last 12 months, in what

months was [] offered by these

programs?

(CIRCLEALLTHATAPPLY)

For which groups was assis

available?

A. Cash 3. No 1. Yes A B C

D _____________ Y

A B C D E F

G H I J K LA B C ____________

B. Rice 3. No 1. Yes A B CD _____________ Y

A B C D E FG H I J K L

A B C ____________

J. Cooking Oil 3. No 1. Yes A B C

D _____________ Y

A B C D E F

G H I J K LA B C ____________

K. Kerosene 3. No 1. Yes A B C

D _____________ Y

A B C D E F

G H I J K LA B C ____________

KSR02:

A. Government

B. Non-government

C. Community self-relian tD. Other, _______________

Y. DONT KNOW

KSR03:

A. January

B. February

C. MarchD. April

E. May

F. June

G. July

H. AugustI. September

J. October

K. NovemberL. December

KSR06:

A. Low-income

B. Everyone

C. Other, _______________

Now,wewouldliketo knowaboutwhethertherewereopportunitiesto purchasefoodat belowmarketpricethroughMarketOperation(OperasiPasar)or CheapPrice(PasarMurah)markets.

KSR07. KSR08. KSR09. KSR11. KSR12.

TYPEOFASSISTANCE

(KSR2TYPE)

In the last 12 months, were there any programs

by regional or national government in your

community to sell [] at below market price?

What was the

source of the

assistance []?

In the last 12 months, in what

months was [] offered by this

program?

Approximately what was the

average savings per unit of

[]?

For which groups was assis

available []?

B. Rice 3. No 1. Yes A B

C Y

A B C D E F

G H I J K L ,Rp/kg A B C ____________

D. Sugar 3. No 1. Yes A B

C Y

A B C D E F

G H I J K L ,Rp/kg A B C ____________

J. Cooking oil 3. No 1. Yes A B

C Y

A B C D E F

G H I J K L ,Rp/kg A B C ____________

M. Other foods/goods

__________________

3. No 1. Yes A B

C Y

A B C D E F

G H I J K LA B C ____________

KSR08:

A. Bulog/Dolog

B. Other government agencies

C. Non-government

KSR09:

A. January

B. February

C. March

E. May

F. JuneG. July

I. September

J. OctoberK. November

KSR12:

A. Low-income

B. Everyone

C. Other, _______________

PKK_PM BOOKPKK- 14 COM

8/13/2019 (04) PKK(CF)

15/17

SECTIONPM:CITIZENPARTICIPATIONY. DONT KNOW D. April H. August L. December

PKK_PM BOOKPKK- 15 COM

8/13/2019 (04) PKK(CF)

16/17

SECTIONKSR:WELFARE

QUESTIONNUMBER NOTES

CP1. Questions with doubtful answers

CP2. Questions needing conversion of measurement unit

CP3. Questions using secondary data source, data unclear

CP4. Other problems

INTERVIEWERNOTE

PKK_KSR1,PKK_KSR2 BOOKPKK- 16 COM

8/13/2019 (04) PKK(CF)

17/17

SECTIONKSR:WELFARE

PKK_KSR1,PKK_KSR2 BOOKPKK- 17 COM