YOUNG LIVES ROUND 4 SURVEY PERU JUNE TO DECEMBER 2013 ...

Young LivesAn International Study of Childhood Poverty

YOUNG LIVES

ROUND 4 SURVEY PERU JUNE TO DECEMBER 2013

COMMUNITY QUESTIONNAIRE

Ninos delMilenioInform ation para el desarrollo

m ^gG R A D EGrupo de Analisis para el Desarrollo

Instituto deInvestigationNutricional UNIVERSITY OF

OXFORD

Young Lives is funded by UK aid from the Department for International Development (DFID)

www.younglives.org-uk

http://www.younglives.org-uk

PROYECTO N IN O S DEL M IL E N IO : UN, GRADE Formato No: Codigo Comunidadc u e s t i o n a r i o d e c o m u n id a d - P e r u , Version 20 Agosto 2013 R4CO M M P E ______ C _______


YOUNG LIVES - PERU

MODULE 1 General Module

Section 1 General Characteristics of the CommunitySection 2 Social EnvironmentSection 3 Access to ServicesSection 4 EconomySection 5 Local Prices

MODULE 2 Child-Specific Module

Section 1 Educational Services (General)Section 2 Educational Services (Primary and Secondary) Section 3 Educational Services - Primary Section 4 Educational Services - Secondary Section 5 Health ServicesSection 6 Child and Adolescent Protection Services

Definition of Community: Administrative areas (zones/neighbourhoods in urban areas and centros poblados/towns in rural areas) normally used as a starting point - this is an operational definition; in this instrument, it is referred as LOCALITY. The administration of this questionnaire will start with this definition in principle and allows for flexibility to expand it depending on each section. For example, the relevant definition of community for the sections included in Module 2 is the one that includes the service providers of each section (e.g. education, health, etc.).

Selection of informants: Each section has a protocol that should be followed in order to identify one or more informants accordingly.


0.1 Locality ID (OBSERVE CODE LIST) PE-_____C _____ PLACEID

Locality Name PLNAME

Neighbourhood BAN AM E

Town TWNNAME

District DISTRIDDISTNAME

Province PROVIDPROVNAME

Department DE PARTI D DEPTNAME

0.2 ID of sentinel site in the Locality (OBSERVE) CLUSTIDField Worker, did you get a copy of the map of the locality?

01=Yes, 00=No, 03= Previously obtained from IN E I (National Statistics Office)MAPLOC

0.3 GPS Coordinates (WGS84) of the Locality (Reference point: Main Square) ONLY FOR NEW COMMUNITIES

SW

____________ ALTITUDE

GPSSTHGPSWESTGPSALTD

Fieldworker: In the case that GPS reference point is not Main Square, please write down the new reference point. REFPOINT

DATA HANDLERS

0.4 Fieldworker code:[_______] SURVCODE

Fieldworker signature:

Date of interview/ / (day / month / year) SURVDATE

0.5 Fieldworker code:[_______] SUPCODE

Fieldworker signature:

Date of Supervision/ / (day / month / year) SUPRVDATE

0.6 Data clerk code:[_______] DATACODE

Data clerk signature:

Date of data entry:/ / (day / month / year) DEDATE

INFORMANT ROSTER (For each Person Interviewed)Note: In case the person does not want to give information on one of these questions,

enter code 79.

0.7.1 0.7.2 0.7.3 0.7.4 0.7.5 0.7.6

Informantcode

Module and Section Name Age Gender Position

Module Section First Name Last name(in years) -77=NK

01 = Male02 = Female

Write the name of the job, post or position

then enter code. (Code Box #1)

(RSID) (MODULE) (SECTION) INFNAME INFSUR (AGERES) (SEXRES) (CAPAC)01 [ _ ] [ _ ] [____] [ ____] [____]02 [ _ ] [ _ ] [____] [ ____] [____]03 [ _ ] [ _ ] [____] [ ____] [____]04 [ _ ] [ _ ] [____] [ ____] [____]05 [ _ ] [ _ ] [____] [ ____] [____]06 [ _ ] [ _ ] [____] [ ____] [____]07 [ _ ] [ _ ] [____] [ ____] [____]08 [ _ ] [ _ ] [____] [ ____] [____]09 [ _ ] [ _ ] [____] [ ____] [____]10 [ _ ] [ _ ] [____] [ ____] [____]11 [ _ ] [ _ ] [____] [ ____] [____]12 [ _ ] [ _ ] [____] [ ____] [____]13 [ _ ] [ _ ] [____] [ ____] [____]14 [ _ ] [ _ ] [____] [ ____] [____]15 [ _ ] [ _ ] [____] [ ____] [____]16 [ _ ] [ _ ] [____] [ ____] [____]17 [ _ ] [ _ ] [____] [ ____] [____]18 [ _ ] [ _ ] [____] [ ____] [____]19 [ _ ] [ _ ] [____] [ ____] [____]20 [ _ ] [ _ ] [____] [ ____] [____]21 [ _ ] [ _ ] [____] [ ____] [____]22 [ _ ] [ _ ] [____] [ ____] [____]23 [ _ ] [ _ ] [____] [ ____] [____]24 [ _ ] [ _ ] [____] [ ____] [____]25 [ _ ] [ _ ] [____] [ ____] [____]26 [ _ ] [ _ ] [____] [ ____] [____]

CODEBOX #1: Job, Post or Position01 = Elected Official 04 = Teacher/ School Principal 07 = Salesman 10 = Villager

02 = Non Elected Official 05 = Religious Leader 08 = Others (Specify): 77 = NK

03 = Health Worker 06 = Leader Female Organisation 09= Community Authority

MODULE 1 - GENERAL MODULESECTION 1 - GENERAL CHARACTERISTICS OF THE LOCALITY

PERSONS ANSWERING THIS SECTION (RSID): Code established in Informant Roster

11 111N F I

12 11IN F2

13 11IN F3

1 .0 Interview begins: Date (D ay) (M o n th ) (Year) INTBEG DT

1 .0 .1 . Interview begins: Hour ____ ■_____ INTBEGH

1.1 Approximately, how many people (including children) live in LOCALITY?

-77= N K

POPSIZE

1.2 Is LOCALITY part of a citv or town?

01=Y es, 0 0 = N o I f NO , SKIP to 1.3

[ ____ ] CITY

1.2.1 What is the name of the city or town? N AM EC ITY

1.2.2 What is the population of that city or town?

-77=NKr i POPCITY

1.3 What is the capital of the district that locality belongs to?

If locality is in the capital of the district, SKIP to 1 .4

CAPDIST

1.3.1 How long does it take to get to the capital of the district? ( in m in u te s )

-88=NA

[ _______ ] TIM EC AP

1.3.2 What is the most common means of transportation used to travel to the capital of the district? You may name up to three, but please name the most common means first. (U se C ode Box #2 )

F ie ld w o rk e r : In th e case m o re th a t o n e m e a n s o f t r a n s p o r ta t io n is re q u ire d to t ra v e l to th e c a p ita l o f th e d is t r ic t (e .g ., f i r s t b y r iv e r , th e n b y ca r) r e p o r t s e p a ra te ly each o f th e s e o n e s (e .g . th e f i r s t as SPCTRAN1, th e se co n d as

SPCTRAN2) s ta r t in g w ith th e o n e th a t c o v e rs m o s t o f th e d is ta n c e .

—TRANS1SPCTRAN1

— TRANS2SPCTRAN2

—TRANS3SPCTRAN3

CODE BOX # 2 - Means of Transportation

01 = By fo o t 0 5 = M o to ta x i 0 9 = T ru c k 77=N K

02 = A n im a l (h o rse , d o n k e y , e tc .) 0 6 = Car 10 = Rail

03 = B icyc le 0 7 = M ic ro , C o m b i, m in ib u s 11 = B o a t

0 4 = M o to rc y c le 0 8 = Bus 13 = O th e r(s p e c ify in th e c o rre s p o n d in g c e ll)

1.4 W hat is the name of the orovincial capital of LOCALITY?

I f lo c a l i t y is lo c a te d in th e p ro v in c ia l c a p ita l, SKIP to 1.5

PRO VCAP

1.4.1 How long does it take get to the provincial capital? ( in m in u te s )

- 7 7 = NS 8 8 = N A[ ---------- ]

T IM P R V C A

1.4.2 W hat is the most common means of transportation used to travel to the provincial capital? You may name up to three, but please name the most common means first.F ie ld w o rk e r : In th e ca se m o re t h a t o n e m e a n s o f t r a n s p o r ta t io n is r e q u ire d t o t r a v e l t o th e c a p ita l o f th e d is t r ic t (e .g ., f i r s t b y r iv e r , th e n b y c a r) r e p o r t s e p a ra te ly e a c h o f th e s e o n e s (e .g . th e f i r s t as SP C TR A N 1, th e

s e c o n d as SP C TR A N 2) s ta r t in g w i t h th e o n e t h a t c o v e rs m o s t o f t h e d is ta n c e .

(C o d e B ox # 2 )

SPCPRTR1 [ ____] PRTRANS1



1.5 W hat are currently the main routes/ways to access LOCALITY?

FIELDWORKER: Fill in a ll o p t io n s w ith e ith e r

01=Y es

0 0 = N o

1. Paved ro a d (PVEDN )

2. E n g in e e re d e a r th ro a d (u n p a v e d ) (EARTHN)

3. M o to r iz e d u n p a v e d ro a d s /tra c k s (U N P A V E D N )

4. N on m o to r iz e d ro a d s /tra c k s ( fo o tp a th s , a p t f o r access by h o rse , d o n k e y s a n d th e like , o r w a lk in g ) (TRACKSN)

5. R iv e r / la k e (RIVERN)

6. O th e rs (s p e c ify ): (O TTR AN N ) (OTRASPEN)

1.6 Which of these routes is the main route to access the LOCALITY?FIELDWORKER: ta k e in to a c c o u n t th e c h a ra c te r is t ic s o f th e la s t k ilo m e tre s o f th e m a in ro u te used to rea ch th e lo c a lity . I f i t is n o t c le a r w h ic h ro u te is

th e m a in o n e , c o n s id e r th e m o s t m o d e rn on e .

Enter code 01-06 from Q.1.5.

[ ____ ] XXX

1.7 In th e p a s t ye a r, has th e m a in ro u te o f access to LOCALITY b e e n INACCESSIBLE in th e fo l lo w in g m o n th ?

ID0 0 = N o ; 01=Y es; 8 8 =N A , 77=N K

1 Ja n u a ry [ ____ ] (JANACC)

2 F e b ru a ry [ ____ ] (FEBACC)

3 M a rc h [ ____ ] (M AR AC C)

4 A p r il [ ____ ] (APRACC)

5 M a y [ ____ ] (M AYACC)

6 June [ ____ ] (JUNACC)

7 Ju ly [ ____ ] (JULACC)

8 A u g u s t [ ____ ] (AUGACC)

9 S e p te m b e r [ ____ ] (SEPACC)

10 O c to b e r [ ____ ] (OCTACC)

11 N o v e m b e r [ ____ ] (NOVACC)

12 D e c e m b e r [ ____ ] (DECACC)

1.8 In relation to the family purchase of food, in which months of the year does the following take place:

1.8.1 1.8.2 1.8.3

Month ID Month Food is more difficult to obtain (scarcity of food) Food is more expensive Families do not have enough money to buy the most important food items(i.e..the most freauentlv consumed items in LOCALITY)

01=Yes, 01=Yes,00= No, 00=No, 01=Yes,

77= NK 77= NK 00=No,77= NK

###SCARC ###EXP ###NOMON

1 January [ ____ ] [ ____ ] [ ____ ]JANSCARC JANEXP JANNOMON

2 February [ ____ ] [ ____ ] [ ____ ]FEBSCARC FEBEXP FEBNOMON

3 March [ ____ ] [ ____ ] [ ____ ]MARSCARC MAREXP MARNOMON

4 April [ ____ ] [ ____ ] [ ____ ]APRSCARC APREXP APRNOMON

5 May [ ____ ] [ ____ ] [ ____ ]MAYSCARC MAYEXP MAYNOMON

6 June [ ____ ] [ ____ ] [ ____ ]JUNSCARC JUNEXP JUNNOMON

7 July [ ____ ] [ ____ ] [ ____ ]JULSCARC JULEXP JULNOMON

8 August [ ____ ] [ ____ ] [ ____ ]

AUGSCARC AUGEXP A U G N O M O N

9 S e p te m b e r [ ____ ] [ ____ ] [ ____ ]

SEPSCARC SEPEXP S E P N O M O N

10 O c to b e r [ ____ ] [ ____ ] [ ____ ]

OCTSCARC OCTEXP O C T N O M O N

11 N o v e m b e r [ ____ ] [ ____ ] [ ____ ]

NOVSCARC NOVEXP N O V N O M O N

12 D e c e m b e r [ ____ ] [ ____ ] [ ____ ]

DECSCARC DECEXP D E C N O M O N

1.9 FIELDWORKER: Write relevant observations/comments in the space below. Write the corresponding question number in the left-hand column.

Entry ID Question # OBSERVATIONS/COMMENTS

ENTRYID QUESTNUM COMMENTS

1

2

3

4

5

1.10 SAY: Now 1 would like to ask you about natural disasters or outbreak of diseases and epidemics that might have occurred at LOCALITY in the last 4 years.

In the past 4 years, has ever been any natural disaster or outbreak of diseases and epidemics that have affected the LOCALITY ? [ ]01=Yes00=No SKIP TO 1.12 77=NS -> SKIP TO 1.12 ( NTRLDIST)

1.10.1 1.10.2 1.10.3 1.10.4 1.10.5In the last 4 years, what was the Please report year and month of What are the two main effects generated by DISASTER in the locality? Approximately what was the Did the locality receive any help?disaster? occurrence of the DISASTER (i.e. when Enter code from CODEBOX #3A percentage (%) of householdsEnter code from CODEBOX # 3. the disaster occurred/began) affected by the event? 00 = No

01=Yes from the GovernmentFIELDWORKER: allow for multiple 01 = Less than 25% 02=Yes from NGOs working here inoccurrences of same event throughout 02 = Between 25 and less than 50% LOCALITYthe years 03 = Between 50 and 90% 03=Yes, from family and friends

04=100% (entire population) 04=Yes, from other institution-77=NK 05=Yes, from NGOs NOT working in-88=NA LOCALITY

88=NAYear

Fieldworker: please record up to2009 three in order of importance2010 Month

First main effect Second main effect2011 1 to 1220122013

DISASTID DISASTER OTHDISTR XXX XXX XXX XXX XXX XXX

1 [ ____ ] 1.1___ ][________ ] [____] [____] [____] [____] 2. [___ ]

3-[___ ]2 [ ] 1. I ___ ]

[________ ] [____] [____] [____] [____] 2. [___ ]3-[___ ]

3 [ ] 1. I ___ ][________] [____] [____] [____] [____] 2 .[___ ]

3 .[___ ]4 [ ] l . [ ___ ]

[________] [___ ] [____] [____] [____] 2 .[___ ]3 .[___ ]

5 [ ] l . [ ___ ][________] [___ ] [___ ] [____] [____] 2 .[___ ]

3 .[___ ]6 [ ] l . [ ___ ]

[________] [___ ] [___ ] [____] [____] 2 .[___ ]3 .[___ ]

7 [ ] l . [ ___ ][________] [___ ] [___ ] [___ ] [____] 2 .[___ ]

3 .[___ ]8 [ ] l . [ ___ ]

[________] [___ ] [___ ] [___ ] [___ ] 2 .[___ ]3 .[___ ]

9 [ ] l . [ ___ ][________] [___ ] [___ ] [___ ] [___ ] 2. [____ ]

3. [___ ]10 [ ] 1. [___ ]

[ ________ ] [ ___ ] [ ___ ] [ ___ ] [ ___ ] 2. [ ___ ]3. [ ___ ]

11 [ ] 1. [ ___ ]

[ ________ ] [ ___ ] [ ___ ] [ ___ ] [ ___ ] 2. [ ___ ]3. [ ___ ]

CODE BOX # 3 - Natural Disaster

01 = V o lc a n ic e ru p t io n 0 4 = M u d a v a la n c h e / s lid e

(h u a yco )

0 6 = O v e r f lo w in g o f

r iv e rs / S u rge o f th e sea

(m a re ta z o )

0 7 = F ro s t/C o ld F ro n t /h a ils to rm 10= O u tb re a k o f p e s ts /d ise a se s a f fe c t in g c ro p s (n o t

caused b y o th e r n a tu ra l d is a s te rs a lre a d y m e n t io n e d )

77=NK

02 = C y c lo n e /to rn a d o

/h u r r ic a n e

0 5 = E a rth q u a k e 16 = H e a vy ra in fa ll 0 8 = F o re s t f ir e 12= O u tb re a k o f pests /d iseases a ffe c tin g live s to ck /a n im a ls

(n o t caused by o th e r n a tu ra l d isaste rs a lrea d y m e n tio n e d )

03 = D ro u g h t 14 = E ro s io n , C racks o r

la n d s lid e (n o t caused by

o th e r n a tu ra l d isa s te rs )

1 5 = T su n a m i 11= O th e r (s p e c ify in th e c o rre s p o n d in g c e ll) VARIABLE 13= O u tb re a k o f pests /d iseases a ffe c tin g h um ans (n o t

caused by o th e r n a tu ra l d isaste rs a lrea d y m e n tio n e d )

CODE BOX #3A - TYPES OF INCIDENTS

01 = P o p u la t io n D is p la c e m e n t 0 4 = Land Loss 10 = C ro p L o ss /F a ilu re 1 4 = B re a k o u t o f p e s ts /d ise a se s a f fe c t in g c ro p s 18= S to ra g e losses

0 8 = P a rtia l h o u s in g d e s tru c t io n 0 5 = C a tt le Loss 11 = E v a c u a tio n ( te m p o ra ry m o v e ) 1 5 = B re a k o u t o f p e s t/d is e a s e s a f fe c t in g liv e s to c k 19= E ro s io n , C racks o r la n d s lid e

0 9 = Full h o u s in g d e s tru c t io n 06= Other (Specify) 12 = T e m p o ra ry is o la t io n / B lockage o f m a in ro u te s /w a y s o f

access

16= C r im e /V io le n c e 8 8 = N A

03 = C hange in th e la n d use 07= Other (Specify) 1 3 = B re a k o u t o f p e s t/d is e a s e s (e .g . d e n g u e , c h o le ra )

a f fe c t in g h u m a n s

1 7 = F a ta lit ie s / d e a th s o f m a n y p e o p le

1.11 Field Worker: W r ite re le v a n t o b s e rv a t io n s /c o m m e n ts on d is a s te rs in th e fo l lo w in g b ox . In d ic a te w h a t d is a s te r yo u re fe r to (ID ). S o m e issues yo u m a y w a n t to e x p lo re in c lu d e : i f th e a id a rr iv e d a t th e

a p p ro p r ia te m o m e n t o r i f i t to o k to o lo n g to g e t to th e lo c a lity , w a s i t w h a t p e o p le n e e d e d th e m o s t, and i f lo ca l a u th o r it ie s d id n o t ask fo r G o v e rn m e n t 's h e lp , w h y n o t?

Disaster ID OBSERVATIONS/COMMENTS

DISASTID DISTCMNT

1

2

3

4

5

6

7

8

9

10

1.12 Currently, does the locality face any risk or vulnerability regarding any natural disasters or climate change? 01=Yes00=No --> Skip to 1.13 77=NK ~> Skip to 1.13

1.12.1 What type of vulnerability the locality faces (for instance, cold, frost, flood, earthquake)?

FIELDWORKER: do not prompt

Enter code from CODEBOX #4

77=NK

1.12.2 Does the authorities, any organization or any organized group had or has been doing any of the following actions to deal with this vulnerability?

Prompt ACTIONS IN 1.12.3

01=Yes00=No Skip to next line77=NK

1.12.3 Which type of ACTIONS?01 = Talks, Workshops02 = Practice drill03 = Civil Defence actions04 = Coastal defence05 = Cleaning of ravines06 = Retaining walls07 = Construction of canals08 = Afforestation, reforestation09 = Specialized study10 = Hazard Map11 = Relocation12 = Other, specify

FIELDWORKER: Select up to three ranked in terms of importance.

VULNID VULN OTHVULN

L____ J L____ J L____ J L____ J L____ J L____ J

L___ ___ ] L__ ___ j L__ ___ j L___ ___ j L___ ___ j L___ ___ j

L____ J L____ J L____ J L____ J L____ J L___ ___ J

L___ ___ J L__ ___ J L__ ___ J L___ ___ J L___ ___ J L___ ___ J

L____ j L____ j L_____ j L____ j L____ j L____ j

L___ ___ J L__ ___ J L__ ___ J L___ ___ J L___ ___ J L___ ___ J

L___ ___ j L__ ___ j L__ ___ j L___ ___ j L___ ___ j L___ ___ j

L___ ___ j L__ ___ j L__ ___ j L___ ___ j L___ ___ j L___ ___ j

L___ ___ J L__ ___ J L__ ___ J L____ J L____ J L____ J

L____ j L____ j L____ j L____ j L____ j L____ j

L_____ J L__ ___ J L__ ___ J L___ ___ J L____ J L____ J

L____ j L____ j L____ j L____ j L____ j L____ j

L____ j L____ j L____ j L____ j L____ j L____ j

L____ J L____ J L____ J L____ J L____ J L____ J

L------- J L------- J L------- J L------- J L------- J L------- J

Codebox # 401 = Slip-prone areas 06 = Overflow of the river 11 = Earthquakes (area with faults, cracks)

02 = Cold (Friaje) 07= Flood 12 = Tsunami Zone03 = Landslide of mud and rock (huayco) 08 = Lagoon overflowing 13 = Hurricane winds04 = Hailstorm 09 = Drought 14 = Settlements in inappropriate places05 = Frost 10 = Heavy rains 15 = High temperatures

16 = Other, specify

1 .1 3 H a v e y o u o b s e rv e d a n y o f t h e f o l lo w in g e f fe c ts in t h e w a t e r a n d s e w e ra g e s y s te m ?

01=Y es 0 0 = N o 77=N K 88 = N A

In th e la s t 3 m o n th s

In th e w a te r so u rce s :

■ R a is ing loss d u e to ch a n g e o f th e r iv e r o r a f f lu e n t s tre a m [ _____ ] (CSFRWTR1)

■ Basin d e fo re s ta t io n a n d la n d s lid e [ _____ ] (CSFRWTR2)

■ D e crea se o f s u p e rf ic ia l o r s u b te r ra n e a n w a te r , d e c re a se o f a q u ife r [ _____ ] (CSFRWTR3)

■ P a rtia l o r to ta l o b s tru c t io n o f r iv e rs s tre a m , e v e n tu a lly o r ig in a t in g m u d a v a la n c h e th a t c o u ld d e s tro y c o lle c t in g w o rk [ _____ ] (CSFRWTR4)

■ S e d im e n t in c re a se o f th e r iv e r s tre a m and w a te r c o n ta m in a t io n o f th e bas in . [ _____ ] (CSFRWTR5)

■ S u b te rre a n w a te r c o n ta m in a t io n d u e to o v e r lo a d o f w a te r b e a rin g . [ _____ ] (CSFRWTR6)

■ N e e d o f w a te r s u p p ly th ro u g h c is te rn , re s u lt in g in q u a lity loss a n d cos ts risen [ _____ ] (CSFRWTR7)

■ OTHERS (S p e c ify ) <S> [ _____ ] (CSFRWTR8)

In th e e le m e n ts c lose to th e r iv e r s tre a m (w a te r in le t , c o lle c t in g , p ip in g ):

■ P a rtia l o r to ta l d e s tru c t io n o f lo c a lis e d c o lle c t in g in r iv e rs o r g u llie s . [ _____ ] (CSFRWTR9)

■ P a rtia l o r to ta l d e s tru c t io n o f c o lle c t in g s tru c tu re s , d w e llin g s , p ip in g , t r e a tm e n t , s to r in g a n d d is t r ib u t io n . [ _____ ] (CSFRW TR10)

■ OTHERS (S p e c ify ) <S> [ _____ ] (CSFRW TR11)

In t r e a tm e n t p la n ts o r re s e rv o irs :

■ G ro u n d s e t t le m e n t , f o r loss in th e g ro u n d re s is ta n c e d u e to s a tu ra t io n [ _____ ] (CSFRW TR12)

■ S tru c tu ra l d a m a g e s d u e to d if fe re n t ia ls s e tt le m e n ts , liq u e fa c t io n o r la n d s lid e , fa ll o f m a te r ia ls o r la n d s lid e [ _____ ] (CSFRW TR13)

■ T o ta l in te r r u p t io n o f th e p ro p e r ru n n in g o f th e t r e a tm e n t o r s ys te m p la n t be ca use o f f lo o d in g , la n d s lid e , e tc . [ _____ ] (CSFRW TR14)

■ D e s tru c t io n o f s to ra g e d c h e m ic a ls used fo r th e w a te r t r e a tm e n t [ _____ ] (CSFRW TR15)

■ R u p tu re o f in c o m in g and e x it p ip e lin e s [ _____ ] (CSFRW TR16)

■ OTHERS (S p e c ify ) <S> [ _____ ] (CSFRW TR17)

In th e p ip e s (d r in k in g w a te r and s e w e ra g e ):

■ D e fo rm a t io n , d ra g g in g o r p ip e lin e ru p tu re d u e to la n d s lid e s o r o th e r ty p e o f d isa s te rs . [ _____ ] (CSFRW TR18)

■ S ilt in g o f e le m e n ts be ca use s e d im e n t d ra g g in g . [ _____ ] (CSFRW TR19)

■ S o lid a c c u m u la t io n in th e se w e ra g e sys te m [ _____ ] (CSFRW TR20)

■ Leak and c o n ta m in a t io n in th e d is t r ib u t io n n e t. [ _____ ] (CSFRW TR21)

■ OTHERS (SPSFRW 22) @ [ _____ ] (CSFRW TR22)

1.14 Could you tell me if the following problems exist in LOCALITY?

1.14.1 1.14.2 1.14.3

ID

Pollution Problems

Is this a problem in LOCALITY?

01=Y es

0 0 = N o ->go to next line

If so, to what extent does it affect LOCALITY?0 1 = S e v e re ly

02=SI ig h t ly

Think about the problem 4 years ago. Compared with now, was it:0 1 = m o re se rio u s

0 2 = a b o u t th e sa m e

03 = less se rio u s

0 4 = d id n o t e x is t

77= NK , 88= NA

Polluted water sources due to:

1 In d u s tr ia l w a s te d e p o s ite d o r d u m p e d a t (o r in ) w a te r sou rce s [ _____ ] (IN D W P R O B ) [ ____] (INDWAFCT) [ ______ ] IN D W P R B 4

2 M in in g w a s te d e p o s ite d o r d u m p e d a t (o r n e a r) w a te r so u rce s [ _____ ] (M IN W P R O B ) [____] (MINWAFCT) [ ______ ] M IN W P R B 4

3 Local fa m il ie s g a rb a g e d u m p e d a t (o r in ) th e s e w a te r sou rce s [ _____ ] (G AR W P R O B) [____] (GARWAFCT) [ ______ ] G A R W P R B 4

4 A n im a l fa e ce s a t (o r in ) w a te r sou rce s [ _____ ] (A N M W P R O B ) [ ____] (ANMWAFCT) [ ______ ] A N M W P R B 4

Polluted lands nearby residential zones, due to the presence of:

5 W a s te la n d (n o n - re g u la te d space ) w h e re f irm s d u m p g a rb a g e [ _______ ] (F R M D U M P ) [ ________] (FIRMAFCT) [ ______ ] F R M D U M P 4

6 W a s te la n d w h e re lo ca l fa m il ie s d u m p g a rb a g e [ _______ ] (FM LY F U M P ) [ ________] (FMLYAFCT) [ ______ ] F M L Y D M P 4

7 W a s te la n d w h e re fa m il ie s f r o m o th e r lo c a lit ie s d u m p g a rb a g e [ _______ ] (LO C LD U M P ) [ ____] (LOCLAFCT) [ ______ ] L O C L D M P 4

8 A n im a ls ' e x c re m e n ts on th e s tre e ts ( o f th e lo c a lity ) [ _______ ] (EXCR D U M P) [ ________] (EXCRAFCT) [ ______ ] E X C R D M P 4

Air pollution due to:

9 G a rb a g e b u rn in g [ _____ ] (G RBBRNG) [ _____ ] (BRNGAFCT) [ ______ ] G R B B R N G 4

10 In d u s tr ia l a c t iv ity [ _____ ] (INDSACTV) [____] (INDSAFCT) [ ______ ] IN D S A C T 4

11 T ru cks , cars, a n d th e lik e pass ing b y LOCALITY [ _____ ] (CARSPSSG) [ ____] (CARSAFCT) [ ______ ] C A R S PSG 4

12 Use o f p e s tic id e s , fe r t i l is e rs in lo ca l a g r ic u ltu ra l lands [ _______ ] (PESTICID) [ ________] (PESTAFCT) [ ______] P E S TIC D 4

Other types of pollution:

13 N o ise p o llu t io n (m o to r v e h ic le s , a irp o r ts , fa c to r ie s ) [ _______ ] (NOISEPLL) [ _____ ] (NOISAFCT) [ ______] N O IS P L L 4

14 S ta n d in g w a te r , o p e n d ra in s (w ith th e c o n s e q u e n t p ro l i fe ra t io n o f m o s q u ito e s , [ _______ ] (STNDW ATR) [____] (WATRAFCT) [ ______ ] S T N D W T R 4

15 O th e rs (s p e c ify ) : (SPCOTHR1) [ _______ ] (O THER1)) [ ________] (OTHAFCT1) [ ______] O T H E R 1 4

1.15 Is there anv recvcle activity in LO C ALITY?[ ] ( RECYCLE )

01=Y es 0 0 = N o 77=N S 8 8 = N A ---------

1.16 Field Worker: Write relevant observations/comments about the ecology and the environmental pollution of the locality in the following box.

S om e e xa m p le s :

W h o a re m o s t a f f l ic te d by th e s e p ro b le m s ( i f c h ild re n p la y in f ie ld s n e a rb y u n s a fe /h a z a rd o u s u n re g u la te d g a rb a g e d ro p p in g f ie ld s , th e y c o u ld s u ffe r f r o m s to m a c h - in fe c t io n s , a n d e ve n re s p ira to ry illn e ss (d u e to g a rb a g e

b u rn in g ) )? I f a ny , ta k e n o te o f th e a c t io n s ta k e n by lo ca l p e o p le to so lve th e p ro b le m .

W h a t a re th e m o s t v is ib le e f fe c ts o f fu m ig a t io n on lo ca l p e o p le 's h e a lth ? (u n e x p la in e d c h ro n ic h e a da ch e s , fa in t , e tc .).

Even w h e n lo ca l p e o p le k n o w th e w a te r so u rce is p o llu te d , th e y s t ill use i t e v e ry d a y . W h y ? Is i t be ca use th e re is n o a lte rn a t iv e w a te r so u rc e n e a rb y ? In th is case, a re lo ca l a u th o r it ie s d o in g s o m e th in g to so lve th e p ro b le m o r

f in d an a lte rn a t iv e ?

Problem ID OBSERVATIONS/COMMENTS

PROBID ECOCMNTS

1

2

3

4

5

6

1.0.2 Interview concludes: Date / / INTENDDT

(Day) (Month) (Year)

1.0.3 Interview concludes: Hour --------• --------- INTENDH

SECTION 2 - SOCIAL ENVIRONMENT

PERSONS ANSWERING THIS SECTION (RSID): Code established in Informant Roster

11 _____ (121N F I)

12 _____ (12 IN F 2)

13 _____ (12 IN F 3)

2.0 Interview begins: Date / /(D ay) (M o n th ) (Year)

INTBEG DT

2.0.1 Interview begins: Hour INTBEGH

2 .1 S A Y : W h ich o f th e fo llo w in g o rg a n ize d arouDs (o rg a n iza tio n / in s t itu t io n / n e tw o rk ! e x is t in L O C A L IT Y ?

2 .1 .1 2 .1 .2

I D

O rga n ize d Groups

Does anv o rg a n iza tio n / in s t itu t io n / n e tw o rk o f th is tv o e e x is t a t L O C A L IT Y ?

01=Yes

00=N o (go to n e x t line)

77=N K (go to n e x t line)

W h a t is th e r o le / p u rp o s e / fu n c t io n o f th is o rg a n iz a t io n / in s t itu t io n ?

(Code Box # 5 )

77=N K

88=N A

1 Labour unions L B R U N IO N

2 C om m unity K itchens C O M M K ITC

3 M o th e r 's Clubs M THRCLUB

4 APAFA (A sso c ia tio n o f s c h o o l's pa re n ts ) (PTAs) APAFA

5 P o litica l groups, re p re s e n ta tiv e s o f P o litica l P arties POLTGRP

6 Relig ious groups, C hurch, e tc . RELGGRP

7 Savings coopera tives SVGSCOOP

8 Housing C oopera tives ( to bu ild houses) HOUSC OOP

9 Lending C oopera tives LENDCOOP

10 S p o rts A ssoc ia tions , S p o rts Clubs SPRTASSC

11 A ssoc ia tions a ga ins t C rim e, e tc . CRMASSC

12 Peasants A ssoc ia tions PS N TA SS C

13 N a tiv e Peoples A ssoc ia tions N T V A S S C

14 A ssoc ia tion f o r A g r ic u ltu ra l Use o f W a te r A G R IA S S C

15 Producers, O rga n iza tio n s PRDCRS

16 O th e r S p e c ifv SPCOTHR1 OTHERS1 RLOTHR1

SPCRLOl

17 O th e r S p e c ifv SPCOTHR2 O TH ER S2 RLOTHR 2

SPCRL02

18 O th e r, S p e c ify SPCOTHR3 O TH ER S3 RLOTHR 3

SPCRL03

19 O th e r S p e c ify SPCOTHR4 O TH E R S 4 R LO THR 4

SPCRL04

20 O th e r, S p e c ify SPCOTHR5 O TH E R S 5 RLO THR 5

SPCRL05

21 O th e r S p e c ify SPCOTHR6 O TH E R S 6 RLO THR 6

SPCRL06

22 O th e r S p e c ifv SPCOTHR7 O TH E R S 7 R LO THR 7

SPCRL07

CODE B O X # 5 - F unction o f O rg a n iza tio n

01 = S p o r t O rga n iza tio n s 0 7 = C ivil O rga n iza tio n s to p ro te c t /S e c u re th e Com m unity 13 = N a tu ra l Resource M anagem ent O rga n iza tio n s ( lik e W a te r A ssoc ia tions)

02 = R e lig ious O rga n iza tio n s 0 8 = O rga n iza tio n s re la te d to C h ild day ca re se rv ices ( lik e W aw a-w asi) 14 = Regional and D ep a rtm e n ta l o rgan iza tions

03 = Labour Unions 0 9 = O rga n iza tio n s th a t c o o rd in a te th e supp ly o f se rv ices ( lik e ta x i assoc ia tions) 15 = O th e r (s p e c ify in th e co rre sp o n de n t space)

0 4 = A r t O rga n iza tio n s 10 = In p u t Purchase O rga n iza tio n s 7 7 = N S

05 = Food S e c u r ity O rga n iza tio n s 11 = M a rk e tin g O rga n iza tio n s 88=N A

06 = O th e r C hild re la te d O rga n iza tio n s (s p e c ify in th e co rrespond ing

ce ll)12 = C re d it and Saving O rga n iza tio n s

2 .2 F ie ld W o rk e r : W r ite down th e name o f th e N S O 's w o rk in a in th is L O C A L IT Y and t h e i r f ie ld a re a

N S O ID 2 .2 .1 N 6 0 Nam e N S O N A M E 2 .2 .2 W h ich o f th e fo llo w in g fu n c tio n does th is NG O do?

(Code Box # 5 ) FNCNGO

SPFNCNGO

1 * [ ]

2 * [ ]

3 ■Sk * [ ]

4 ■Sk * [ ]

5 ■Sk * [ ]

6 ■Sk * [ ]

7 ■Sk * [ ]

8 ■Sk * [ ]

2.3 Field Worker: Write relevant observations/comments on organized groups. Write the group ID to which the comment refers.

Group ID OBSERVATIONS/COMMENTS

G RO UPID ORGCMNTS

1

2

3

4

5

2.4 SAY: Now 1 would like to ask vou about local social problems that mav be affecting the local residents of LOCALITY.

FIELDWORKER: In ca se th e p ro b le m d o e s n o t ta k e p la c e w i t h in th e lo c a l a re a ( b u t s t i l l a f fe c ts lo c a l re s id e n ts , in c lu d e i t in " O th e r s , " s p e c ify in g w h e re i t ta k e s p la c e .)

ID 2.4.1 2.4.2 2.4.3

Social Problems

Is this a problem in LOCALITY?

01=Yes

0 0 = No

Are you, the local residents, organized in any way against this problem?

01=Yes

0 0 = No

77=N K

Over the last 4 years (or since it first appeared, if it's been present for less than 4 years), has this problem diminished?

0 0 = Yes, totally d u e to th e o rg a n iz a t io n o f th e lo c a lity

01=Y es, partially d u e to th e o rg a n iz a t io n o f th e lo c a lity

02=Y es, d u e to th e p o lic e

03=Y es, d u e to o th e r re a so n (s p e c ify in th e c o r re s p o n d in g ce ll)

0 4 = N o , i t re m a in s

0 5 = N o , th e p ro b le m is b ig g e r n o w

0 6 = N o , n e v e r ex is ts

77=N K

1 T h e ft / ro b b e ry ROBBERY ASSTRBRY 04YRRBBR

SPCRBBRY2 C a ttle /liv e s to c k th e f t C T T L T H F T A S S T C T T L 0 4Y R C T T L

SPCCTTL

3 P ro s titu tio n in th e loca l area P R S T IT N A S S TPR S T 04YR P R ST

SPCPRST

4 Juven ile gangs <9AN(9S A<9ST<9N<9S 04YR(9N<9S

SPCSNSS

5 Local a d u lt b a n d s /g ro u p s r iv a lry (p o litica l, e th n ic , e co n om ic -w ise ) A D LT B N D S A S S T A D L T 0 4 Y R A D L T

SPCADLT6 Illega l d rugs se lling in th e local area DRUSSLLS A(9STSLL<9 04Y R S LLS

SPCSLLS

7 D rugs-add ic ts in th e local area (e ith e r res ide n ts o r o u ts id e rs co n su m in g

illega l d rugs in th e loca l area)

DRUSADC T A S S T A D C T 04Y R A D C T

SPCADCT

8 A lco h o lism ALC H LS M A S S T A LC H 04Y R A LC H

SPCALCH

9 V io le n t c rim es VLNTCRM E A S S T V L N T 0 4 Y R V L N T

SPCVLNT

10 O the rs (Specify): (SPCPRB1) OTHRPRB1 A S S T O T H 1 0 4 Y R 0 T H 1

11 O the rs (Soecifv): (SPCPRB2) OTHRPRB2 A S S T O T H 2 0 4 Y R 0 T H 2

2.5 Field Worker: W rite relevant observations/comments in the following box about family violence and about risk factors for children and adolescents in the area. W rite the corresponding question number on the left.

Entry ID OBSERVATIONS/COMMENTS

F M LY V LID FM LYC M NTS

1

2

3

4

2.0.2 Interview concludes: Date / / INTENDDT


2.0.3 Interview concludes: Hour ---------• ---------- INTENDH

SECTION 3 ACCESS TO SERVICES

PERSONS ANSWERING THIS SECTION (RSID): 11 [ ____ ] 131N F I

Code established in Informant Roster 12 [ ____ ] 13IN F2

13 [ ____ ] 13IN F3

3.0 Interview begins: Date / /(Day) (Month) (Year)

INTBEG DT

3.0.1 Interview begins: Hour ------: ------- INTBEGH

3.1.1 3.1.2 3.1.3

Is the following service Approximately how long takes going to the centre of the LOCALITY to the nearest Which mean of transport is the most common?

N° Services

currently available at LOCALITY?

service using the most common mean of transport?

01=Y es Skio to next line /service W r ite d o w n th e n u m b e r o f m in u te s

Use C ode b o x # 2

0 0 = N o -77=N S , 8 8 = NA

8 8 = N A

1 URB - R e c re a tio n a l a reas : C h ild re n 's P la yg ro u n d s

RUR - SDace e x c lu s iv e ly ass igned fo r l i t t le c h ild re n to D lav ( i t m ig h t

be an ODen f ie ld as lo n g as it is c le a n a n d s a fe /s e c u re )[ _____ ] LTTLCHLD

2 URB - R e c re a tio n a l a reas : fo o tb a ll (so cce r) f ie ld , v o lle y b a ll f ie ld , e tc .

RUR - Space e x c lu s iv e ly ass igned fo r c h ild re n a n d a d o le s c e n ts to

e x e rc is e /p ra c t ic e a s p o r t ( it m ig h t be an o p e n f ie ld as lo n g as it is

c le a n and s a fe /s e c u re )

[ _____ ] ADLSCNT

3 URB - R e c re a tio n a l A re a s : c a m p in g zones o f fa m ily re c re a t io n a l

areas [ _____ ] FM LYC M PG

4 Movie Theatre / Public place for playing films [ _____ ] THEATRE

5 Video Game [ _____ ] V ID E O G M S

6 Cock fighting arenas / Bull fighting arenas [ _____ ] BULLFIGHT

7 Space for Fairgrounds / Circus (temporary recreational activities)[ _____ ] FAIRGRND

8 Slot Machines / Casino [ _____ ] SLOTMCH

9 Religious institutions, Churches [ 1 RELGINST [ ] @ [ 1

TIM ER ELG TRNSRELG SPCTRRLG

10 Public Telephones, community phone, rural phone [ 1 PBLTELE [ ] @ [ 1

TIM ETELE TRNSTELE SPCTRTEL

11 Private telephone (at least one connection) [ _____ ] PRVTELE

12 Public Internet Cabin[ _____ ] PBLINRNT

[ _________]

T IM E IN T R

@ [ 1

TRNSINT SPCTRINT

13 Electricity (at least one connection) [ _____ ] ELCTRCTY

14 Public water supply (at least one connection) [ _____ ] DRNKW ATR

15 Sewerage (at least one connection) [ _____ ] SEW AGER

16 Police Station[ _____ ] PLCSTTN

[ _____ ]

T IM EP O LC

@ [ 1

TRNSPOLC SPCTRPOL

17 Non Professional judge[ _____ ] NO N JUD G

[ _________]

T IM E N O N

@ [ 1

TRN NO N JG SPCTRNON

18 Professional judge[ _____ ] PROFJUDG

[ _________]

T IM EPR O F

@ [ 1

TRNPROJG SPCTRPRO

19 N a t io n a l B a n k[ _____ ] NTLBANK

[ _________]

T IM E N A T L

@ [ 1

TRN N TA BK SPCTRNAT

20 O th e r p r iv a te b a n k s[ _____ ] O THRBANK

[ _________]

T IM E P R IV

@ [ 1

TR N O TH BK SPCTRPRI

29 B a n k a g e n ts (e .g . a m in i-m a rk e t , p h a rm a c y th a t a llo w s w ith d ra w in g

m o n e y a n d d e p o s it m o n e y )

[ _____ ] [ _________] @ [ 1

21 C aja R u ra l / M u n ic ip a l (L o ca l g o v e rn m e n t c r e d it /s a v in g s sc h e m e s )[ _____ ] LCLGOVRN

[ _________]

T IM E G O V

@ [ 1

TRNSGOV SPCTRGOV

22 In fa n t d a y c a re c e n tre[ _____ ] INFDAYCR

[ _________]

T IM E D A Y

@ [ 1

TRNSDAY SPCTRDAY

23 C h ild P ro te c t io n S e rv ice s (D E M U N A ,D N A )[ _____ ] D E M U N A

[ _________]

TIM EPRC

@ [ 1

TRNSPRC SPCTRPRC

24 C ab le T V - P r iv a te S ys te m [ _____ ] PRVCBLTV

25 C ab le T V - P u b lic S ys te m [ _____ ] PUBCBLTV

32 C ell p h o n e s e rv ic e [ _____ ] CELLPHNE

27 SERPOST - C e r t i f ie d m a il[ _____ ] SERPOST

[ _________]

T IM ESER

@ [ 1

TRNSSER SPCTRSER

28 O th e r (S p e c ify ) : <® SPCSERV1[ _____ ] OTHSERV1

[ _________]

T IM E O T H 1

@ [ 1

TRNSOTH1 SPCTROT1

CODE BOX # 2 - Means of Transportation

01 = By fo o t 0 5 = M o to ta x i 0 9 = T ru c k 13 = O th e r(s p e c ify in th e c o rre s p o n d in g c e ll)

02 = A n im a l ( h o rs e / d o n k e y ) 0 6 = Car 10 = Rail 77=N K

03 = B icyc le 0 7 = M ic ro , C o m b i 11 = B o a t

0 4 = M o to rc y c le 0 8 = Bus

3.2 FIELDWORKER: Write down comments in the following box and the corresponding question number to the left. For example if churches provide other services additional to the religious ones. For example, provision of health or educational services, orientation for family violence issues, and so on. In case the church plays an important role in the locality, explain the characteristics of this role.


ENTRYID COMMENTS

1

2

3

4

3.3 3.3.1SAY: Which are the most common places where people relieve themselves / do their business / defecate? Approx, what percentage of houses use this system?

F ie ld w o rk e r : P lease m a k e s u re c a te g o r ie s su m 100.

ID PLACES

01=Y es

0 0 = N o ->go to next line 77=N K ->go to next line

-77 = N K

-8 8 = N A

1 F lush t o i le t / s e p tic ta n k w ith in th e h o u s e h o ld [ _____ ]TOI LETIN f 1N U M IN TLT

2 F lush t o i le t / s e p tic ta n k o u ts id e th e h o u se (c o m m u n a l) [ _____ ]TO ILT O U T [ ] N U M O U T T L

3P it la t r in e in s id e th e d w e llin g , used e x c lu s iv e ly b y th e h o u s e h o ld [ _____ ] PITIN

f 1 N U M IN P IT

4 P it la t r in e o u ts id e th e d w e llin g , used e x c lu s iv e ly b y th e h o u s e h o ld [ _____ JPITOUT [ ] N U O U TPT

5 P it la t r in e used b y a n y m e m b e r o f th e lo c a lity [ _____ ]SHRPIT [ ] N U M SH R P T

6 H ill, o p e n f ie ld , b u shes [ ______]H ILLO PEN [ ] N U M H IL L

7 R ive r, s tre a m , ca n a l [ ______]R VRTO ILT [ ] N U M R IV E R

8 O th e r : (SPEC TO LT) [ _____ ]O THR TO LT [ ] N U M O T H R

3.4 3.4.1 3.4.2 3.4.3 3.4.4What are the main places where residents of LOCALITY get their drinking water from?

01=Y es

0 0 = N o SKIP to next line

On average, how many hours per day is there access to water? 77=N K

88 = N A

How many days per week? 77=N K

8 8 = N A

Approx, what percentage of dwellings have it?-77 = N K

-8 8 = N A

1 P ip e d in to d w e l l in g /y a rd /p lo t (p u b lic ) PIPEDW LL DAYS N U M IN D W L

2 P ip e d w a te r (p r iv a te , c o n n e c te d t o a n y o th e r w a te r PIPEW ATR N U M P IP W T

3 P riv a te tu b e w e ll PRVTTUBE N U M T U B E

4 P u b lic fo u n ta in PUBFNTN N U M F N T N

5 P u b lic W e ll PUBW ELL N U M W E L L

6 W a te r t ru c k W TRTRUCK

7 S p r in g /p o n d / r iv e r /s t r e a m SPRING

8 O th e r: (SPECOTHR) OTHER

FIELDWORKER: ONLY if 3.4.1_01 = 01 -» continue to 3.5; otherwise -» Skip to 3.6

3.5 3.5.1 3.5.2 3.5.3 3.5.4

In case there is public water supply, what type of Currently, is the water being treated for If so, with which type of treatment? How often is the treatment beingconnection is it? drinking? applied?

0 0 = N o 0 0 = N o 0 0 = D oes n o t re c e iv e t r e a tm e n t

ID Type of Water supply 01=Y es 01= Yes 0 1 = T re a te d u s in g c h e m ic a ls (b le a c h , c h lo r in e , e tc .) See C o d e b o x # 6

8 8 = N A 0 2 = T re a te d u s in g f i l te rs /c a rb o n

88 = N A 0 3 = U s in g o th e r t r e a tm e n ts (s p e c ify )

8 8 = N A

1 P u b lic w a te r s u p p lie s h a n d le b y a [ 1c h a rg in g fa re c o m p a n y , ( i .e . : SEDAPAL)

TYPCHRG

2 P u b lic w a te r s u p p lie s h a n d le d b y an r 1 [ ] [ ] [ ]N G O , o r lo ca l g o v e rn m e n t (c h a rg in g

L_____ J

fa re o r n o t) TYPNG O W H T R N G O O FTN N G O

SPW HTNGO SPOFTNGO

3 O th e r (specify): (SPCTYPRD)[ _____ 1 [ ______] [ _____ ] [ ______]

@W H T R W T O T O FTN W TO T

TYPW TOTH S P W H TW TO T SPOFTW TO

CODE BOX #6 - FRECUENCIES

0 1 = D a ily 0 4 = M o n th ly 0 7 = H a lf-y e a r ly 10=Others (Specify)

0 2 = W e e k ly 0 5 = E v e ry tw o -m o n th s 0 8 = A n n u a lly 8 8 = N A

0 3 = E v e ry tw o w e e k s 0 6 = Q u a r te r ly 0 9 = lr re g u la r

3 .6 3 .6 .1 3 .6 .2 3 .6 .3

ID

W a y s o f g a rb a g e c o lle c t io n /d is p o s a l

W h a t a re th e m a in p la c e s o r w a y s re s id e n ts o f LOCALITY d is p o s e

o f t h e i r g a rb a g e ?

01=Y es

0 0 = N o (g o t o n e x t lin e )

O n a v e ra g e , h o w m a n y d a y s p e r

m o n th is g a rb a g e c o lle c te d ?

77=N K

In d ic a te th e m o s t c o m m o n g a rb a g e c o l le c t io n m e th o d s

in o rd e r o f im p o r ta n c e :

01= m o s t c o m m o n

02= se co n d m o s t c o m m o n

03= th ir d m o s t c o m m o n

0 0 = n o t o n e o f th e m o s t c o m m o n ones

1 C o lle c te d th ro u g h g a rb a g e tru c k s [ ______ ( gr bg tr c k [ _____ ] GRBCLCT [ ______] CMNTRUCK

2 T h ro w n in to s tre e t [ ______ (STREET [ ______ ] CMNSTRET

3 D u m p e d on w a s te la n d (u n re g u la te d sp o ts ) [ ______ (WASTLAND [ ______] CMNWSTLN

4 S e n t to re g u la te d spaces ass igned fo r g a rb a g e d u m p in g [ ______ (REGULATE [ ______] CMNREGLT

5 T h ro w n in to r iv e r /c a n a l, lake [ ______ (RIVERGRB [ ______ ] CMNRIVER

6 B u rie d[ ______ (BURIED [ ______ ] CMNBURD

7 U sed o n c ro p f ie ld s [ ______ (CROPFLDS [ ______ ] CMNCROP

8 B u rn t [ ______(BURNT [ ______ ] CMNBRNT

9O th e rs : (SPECGRB) [ ______(OTHRGRB [ ______ ] CMNOTHR

3.0.2 Interview concludes: Date / /


INTENDDT

3.0.3 Interview concludes: Hour ---------• ---------- INTENDH

SECTION 3B ProgramsPERSONS ANSWERING THIS SECTION (RSID): 11 [ ____ ] 1 PI N F I

Code established in Informant Roster 12 [ ____ ] 1PINF2

13 [ ____ ] 1PINF3

3 .0.4 Interview begins: Date / /(Day) (Month) (Year)

INTBEG DT

3 .0.5 Interview begins: Hour ------: ------- INTBEGH

3.7 SAY: Does this programme currently operate at LOCALITY? (Ask for each type of programme.)

F ie ld w o rk e r : P a v s p e c ia l a t te n t io n to o ro a ra m m e s t h a t a f fe c t c h ild re n , a d o le s c e n ts a n d o re a n a n t m o th e rs ' in LOCALITY, e s p e c ia lly w h e n a s k in a f o r "O th e rs " .

3.7.1

ID

Type of Programme

Does this programme currently operate at LOCALITY?

01=Y es, 0 0 = N o , 77=N K

Food assistance Programs

1 Glass o f M i lk P ro g ra m GLSSMILK

2 C o m m u n ity K itch e n C O M M K IT C

3 Food fo r W o rk FO O DW O R K

5 C o m p re h e n s iv e N u t r i t io n P ro g ra m m e (PN I)

K n o w n as C o m p le m e n ta ry F e e d in g P ro g ra m (PACFO) b e fo re

COM PFEED

6 O th e r (S p e c ify ): SPCFOOD1 O TH FO O D 1



Education Programs

57 C unam as

9 W a w a W a s i (o r a n y o th e r su b s id ize d D ay C are C e n tre fo r c h ild re n b e tw e e n ages 0 -3 ) W A W A W A S I

10 PRONOEI (su b s id ize d n o n - fo rm a l p re s c h o o l) o r CEI (p u b lic fo rm a l p re s c h o o l) fo r c h ild re n b e tw e e n ages 3 -5 PRONOEI

11 S choo l B re a k fa s t / Lunch (PR O N A A Q A L IW A R M A ) SCHBKFST

12 S choo l C lo th s , shoes, tra c k s u it SCHCLTH

13 S choo l T ex ts / s u p p lie s SCHLTEXT

14 L ite ra c y C a m p a ig n / P R O N A M A LITRCY

58 PR O M O LIBR O PR O M LIBR

59 A lte rn a t iv e Basic E d u c a tio n - (EBA) ALTBSCED

60 A L a p to p /P C /C o m p u te r p e r C h ild LAPTOPCH

15 O th e r (S p e c ify ): SPCEDUC1 EDUCTN1

16 O th e r (S p e c ify ): SPCEDUC2 EDUCTN2

17 O th e r (S p e c ify ): EDUCTN3

Health Programs

18 In te g ra l H e a lth In s u ra n c e (SIS) HLTHINSR

19 G ro w th and D e v e lo p m e n t P ro g ra m - CRED

21 T u b e rc u lo s is C o n tro l TUBCNTRL

26 M a la r ia P re v e n tio n P ro g ra m , D e n g u e P re v e n tio n P ro g ra m

27 H IV /S ID A P ro g ra m HIVSIDA

28 M e n ta l H e a lth P ro g ra m M EN TLH TH

29 P ro g ra m s o r ie n te d to a d o le s c e n ts to c o n tro l STDs CNTRLSTD

30 O th e r (S p e c ify ): SPCHLTH1 HLTHOTH1

31 O th e r (S p e c ify ): SPCHLTH2 HLTH OTH2

32 O th e r (S p e c ify ): SPCHLTH3 HLTH OTH3

Infrastructure Programs

33 C o n s tru c t io n / r e p a ir o f S ch o o l In f ra s tru c tu re / e q u ip p in g RPRSCHL

34 C o n s tru c t io n / r e p a ir o f h e a lth fa c il it ie s In f ra s t ru c tu re / e q u ip p in g RPRHLTH

35 C o n s tru c t io n / r e p a ir w a te r sys te m s RPRWTR

36 C o n s tru c t io n / r e p a ir s e w e ra g e RPRSWR

37 C o n s tru c t io n o f P it la tr in e s RPRPIT

38 C o n s tru c t io n o f b r id g e s a n d roa d s RPRBRDG

39 C o n s tru c t io n / r e p a ir o f p la t fo rm s , r id g e s RPRAND

4 0 R e fo re s ta t io n P ro g ra m s REFOREST

41 Ir r ig a t io n P ro g ra m s IRRGTN

4 2 O th e r (S p e c ify ): SPCINFR1 INFROTH1

4 3 O th e r (S p e c ify ): SPCINFR2 INFRO TH2

4 4 O th e r (S p e c ify ): SPCINFR3 INFRO TH3

Other Programs

4 5 A g r ic u ltu re T e c h n ic a l A ss is ta n ce AGRITECH

4 6 A n im a l H e a lth S e rv ices A N IM A L

4 7 A g r ic u ltu re In p u t d e liv e ry A G R IN P U T

4 8 T it l in g P ro g ra m TITLING

4 9 T e c h n ic a l A ss is ta n ce in : SPECTECH TECHNCAL

50 M ic ro c re d it P ro g ra m s M ICROCRD

51 P ro g ra m to s u p p o r t la b o u r e n ro lm e n t : A t ra b a ja r U rb a n a / A T ra b a ja r R ural LABORENR

52 R ecyc le P ro g ra m RECYCPRG

53 JUNTOS P ro g ra m JUNTOPRG

61 P ens ions 65+

62 F O N C O D E S /H A K U U IN AY

63 PRO JOVEN

54 O th e r (S p e c ify ): SPCOTH1 OTHOTHR1

55 O th e r (S p e c ify ): SPCOTH2 O TH OTHR2

56 O th e r (S p e c ify ): SPCOTH3 O TH OTHR3

3.8 Field Worker: Write relevant observations/comments in the following box. Write first the number of the question you refer to.


ENTRYID PRGCM NTS

1

2

3



IN TEN D D T

3.0.7 Interview concludes: Hour ------: ------- INTENDH

Section 4 - ECONOMY

4.0 PERSONS ANSWERING THIS SECTION (RSID): Code established in Informant Roster

11 [ ____ ] 14 IN F1

12 [ ____ ] 141NF2

13 [ ____ ] 141NF3

Interview begins: Date / /(Day) (Month) (Year)

IN TBEG D T

4.0.1 Interview begins: Hour ------ : ------- INTBEGH

4.1 SAY: 1 would like to ask vou about the dailv wage paid at LOCALITY for several types of work.

FIELDW ORKER: In th e case w h e re fa rm in g a c t iv it ie s a re n o t p e r fo rm e d in th e lo c a lity , go to question 4.24 .1.1 4 .1.2 4 .1.3 4 .1.4 4 .1.5 4 .1.6

ID What is the average daily Additional to the What is the average daily wage a FEMALE Additional to the monetary wage, What is the average daily wage or Additional to the monetary transfer,wage a MALE ADULT earns monetary wage, does he ADULT earns for this type of work? does she receive any other benefit? tip a CHILD receives for helping with does s/he receive any other benefit?for this type of work? receive any other (you can mark more than one this type of activity? (you can mark more than one

benefit? -1 1 = th e y d o n o t w o r k in th a t ty p e o f jo b option) option)-1 1 = th e y d o n o t w o rk in (you can mark more -2 2 = th e y a re n o t p a id fo r th a t -1 1 = th e y d o n o t w o r k in th a t ty p e o f

th a t ty p e o f jo b than one option) -77= N K 0 0 = N o , she d o e s n o t re c e iv e a n y jo b 0 0 = N o , s /h e d o e s n o t re c e iv e any

-2 2 = th e y a re n o t p a id fo r -8 8 = N A a d d it io n a l b e n e f it -2 2 = th e y a re n o t p a id fo r th a t a d d it io n a l b e n e f it

th a t 0 0 = N o , he d o e s n o t 0 1 = B re a k fa s t -77= N K 01= B re a k fa s t

-77= N K re c e iv e a n y a d d it io n a l 0 2 = Lunch -8 8 = N A 02= Lunch

-8 8 = N A b e n e f it 0 3 = A d r in k (s ) 03= A d r in k (s )

0 1 = B re a k fa s t 0 4 = A c ig a re tte (s ) 04= A c ig a re tte (s )

0 2 = Lunch 05=C oca leaves 05=C oca leaves

0 3 = A d r in k (s ) 0 6 = O th e r (s p e c ify in th e 0 6 = O th e r (s p e c ify in th e

0 4 = A c ig a re tte (s ) c o r re s p o n d in g ce ll) c o rre s p o n d in g c e ll)

05=C oca leaves 77=N K 77=N K

0 6 = O th e r (s p e c ify in th e 88 = N A 8 8 = N A

c o rre s p o n d in g c e ll)

77=N K

88 = N A

1 A gricu ltu re A c tiv ity [ ______ . _ ] A G R IM A L E [ ______ ] M M O N A G R I [ ______ . ___ ] A G R IF M L E [ ______ ] F M O N A G R I [ ______ . ___ ] A G R C H L D [ ______ ] C M O N A G R I

O S P C M A G R I <a S P C FA G R I (5) SP CA G R I

2 A n im a l h u s b a n d ry [ _____■ _ ] [ _____] [ _____ • _ ] [ _____ ] [ _____■ _ ] [ _____ ]<s> <s> <®

3 O ther, specify [ ______ . _ ] O T H R M A L E [ ______ ] M M O N O T H R [ ______ . _ ] O T H R F M L E [ ______ ] F M O N O T H R [ ______ . _ ] O T H R C H L D [ ______ ] C M O N O T H R

<S S P C M O T H R <S S P C FO TH R (5) S P C C O TH R

(SPECTYPE)

4.2 Field Worker: Take note of the local average value of each type of foods, candy, drinks, etc. that the worker receives additional to their daily wage (so it is possible to estimate the total value of a whole day of work in the locality).

ID Type of product/ meal Average Local PriceFOODID TYPEFOOD AVGPRCE

1

2

3

4

5

6

7

8

4.3 Field Worker: Write relevant observations/comments on the type of work that children do. Pay special attention to the gender roles in the locality. For example, if girls do not go out from home to work in other farms, but stay at home to help with domestic work only.


VA LU EID V A LU C M N T

1

2

3

4

5

6

4 .4 SAY: 1 would like to ask you about the wages paid at LOCALITY for several types of work.

4 .4 .1 4 .4 .2 4 .4 .3

ID What is the typical Monthly wage an ADULT MALE earns for this type of work?-1 1 = th e y d o n o t w o r k in th a t

ty p e o f jo b

-2 2 = th e y a re n o t p a id fo r th a t

-77= N K , -8 8 = N A

What is the typical Monthly wage an ADULT FEMALE earns for this type of work?-11 = th e y d o n o t w o rk in th a t ty p e o f jo b

-22 = th e y a re n o t p a id fo r th a t

-77= N K

-8 8 = N A

What is the typical Monthly wage or tip a CHILD receives for helping with this type of activity?-1 1 = th e y d o n o t w o r k in th a t ty p e o f jo b

-2 2 = th e y a re n o t p a id fo r th a t -77= N K

-8 8 = N A

1 L a u n d ry (m a n u a l c lo th e s w a s h in g ) [ _____ . ] LNDRMALE [ _____ . ] LNDRFMLE [ _____ . _ ] LNDRCHLD

2 H e lp in g a t w o rk s h o p s (d iv e rs e tasks lik e p a in t in g g lass o r w o o d ,

o rg a n iz in g m a te r ia ls in th e w o rk s h o p , e tc .)[ _____ . ] HELPMALE [ _____ . ] HELPFMLE [ _____ . ] HELPCHLD

3 C o n s tru c t io n w o rk e r [ _____ . ] CNSTMALE [ _____ . ] CNSTFMLE r 1 CNSTCHLD

4 F a c to ry w o rk e r [ _____ . ] FACTMALE [ _____ . ] FACTFMLE [ _____ . ] FACTCHLD

5 P a p e r B oy [ _____ . ] PAPRCHLD

6 S h o e b la c k /S h o e s h in e B oy [ _____ . ] SHOECHLD

7 Car w a s h e r [ _____ . ] CARWCHLD

8 C h ild s tre e t v e n d o r r 1 STVNCHLD

9O th e r (s p e c ify ) : (SPCW ORK1) [ _____ . ] OTHMALE1 [ _____ . ] OTHFMLE1 [ _____ . _ ] OTHCHLD1

10 O th e r (s p e c ify ) : (SPCW ORK2) [ _____ . ] OTHMALE2 [ _____ . ] OTHFMLE2 [ _____ . _ ] OTHCHLD2

11 O th e r (s p e c ify ): (SPCW ORK3) [ _____ . _ ] OTHCHLD3

12 O th e r (s p e c ify ) : (SPCW ORK4) [ _____ . _ ] OTHCHLD4

4.5 FIELDWORKER: Write relevant observations/comments on the type of work that children do. Pay special attention to gender differences. F or e x a m p le , i f g ir ls d o n o t g o o u t f r o m h o m e to w o rk in m a rk e t

jo b s , b u t s ta y a t h o m e to h e lp w ith d o m e s t ic w o rk o n ly , w h y d o e s th is h a p p e n ? W h a t o th e r ty p e s o f w o rk d o c h ild re n p e r fo rm , e ve n w h e n th e y d o n o t re c e iv e a n y pay fo r th e m (h e lp in g th e ir p a re n ts to

b re a k d o w n s to n es , b ricks , e tc .) . D o th e c h ild re n re c e iv e a n y o th e r ty p e o f p a y m e n t ( fo o d , e tc .) in s te a d o r a d d it io n a l t o th e d a ily w a g e ? I f so, s p e c ify w h a t ty p e o f jo b (ID ) y o u re fe r to , a n d h o w m u c h th a t

n o n -m o n e ta ry p a y m e n t w o u ld co s t in th e lo c a lity .


W O R K ID W O R K C M N T

1

2

3

4

4.6 What is the averaee monthlv wage earned bv a Teacher of a Public Primarv School at LOCALITY, hired under temoorarv contract? TCHTEM P

-77=N K , -8 8 = T h e re is n o P r im a ry S choo l h e re [ ____ ]4.6.1 What is the averaee monthlv waee earned bv a Teacher of a Public Primarv School at LOCALITY, hired as public official (stable iobl? TCHPUB

-77=N K , -8 8 = T h e re is n o P r im a ry S choo l h e re [ ____ ]

4.7 What is the averaee monthlv waee earned bv a Nurse workine at a Public Health Centre at LOCALITY, hired under temporary contract?

-77=N K , -8 8 = T h e re is n o P u b lic H e a lth C e n tre h e re [ ____ ]

NURSTEM P

4.7.1 What is the averaee monthlv waee earned bv a Nurse workine at a Public Health Centre at LOCALITY, hired as public official?

-77=N K , -8 8 = T h e re is n o P u b lic H e a lth C e n tre h e re [ ____ ]

NURSPUB

4.8 What is the averaee monthlv waee earned bv a Municipal / Community Secretary at LOCALITY?

-77=N K , -8 8 = N A [ ____ ]

SECRTRY

4.9 Field Worker: Write relevant observations/comments below:


ENTRYID 4 9 C M N T

1

2

3

4

5

6

7

8

4.0.2 Interview concludes: Date / /(Day) (Month) (Year)

IN TEN D D T

4.0.3 Interview concludes: Hour ____ • _____ INTEN DH

Section 5 - PRICES

PERSONS ANSWERING THIS SECTION (RSID): Code established in Informant Roster 11____ 15INF1

12____ 15INF2

13____ 15INF3

14____ 15INF4

15____ 15INF5

16____ 15INF6

17____ 15INF7

18____ 15INF8

19____ 15INF9

110____ 15INF105.0 Interview begins: Date / / (Day) (Month) (Year) (INTBEGDT)

5.0.1 Interview begins: Hour (INTBEGH)

5 .1 L is t t h e p r ic e s o f t h e f o l lo w in g i t e m s . Loca l c u r re n c y : N u e v o s S o le s . F o r V e n d o r C o d e s , use C ode B o x # 8 .

ID ITEM DESCRIPTION U N ITVENDOR 1 VENDOR 2

P r ic eV E N D O R C o d e IN F O R M A N T

C o d eP r ic e

V E N D O R C o d e IN F O R M A N TC o d eS ee C o d e b o x # 8 S ee C o d e b o x # 8

### #P R C 1 S P C # # # # 1 # # # # V N D 1 # # # IN F 1 ### #P R C 2 S P C # # # # 2 # # # # V N D 2 # # # IN F 2

E D U C A T IO N

1 S m a ll N o te b o o k 1 0 0 p a g e s O ne r . l ^ r 1 [ ______ ] r . l ^ r l [ ______ ]

2 S h o e s S ch o o l sh o e s , fo r a 12 y e a r -o ld b o y O n e p a ir r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

3 B o y 's s h ir tW h ite , s h o r t s le e v e , fo r a 12 y e a r-o ld b o y , m e d iu m q u a lity

O n e s h ir t r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

4 G ir l 's b lo u seW h ite , s h o r t s le e v e , fo r a 12 y e a r-o ld g ir l , M e d iu m q u a lity

O n e b lo u se r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

5 B o y 's p a n ts / t r o u s e rsB la c k p a n ts , fo r a 12 y e a r -o ld b o y , m e d iu m q u a lity

O n e p a ir o f p a n ts

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

6 G ir l's s k ir tB la c k , fo r a 12 y e a r -o ld g ir l, M e d iu m q u a lity

O n e s k ir t r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

H E A L T H

7O ra l re h y d ra tio n sa lts 27.5 g sa ch e t W H O , S alvadora One sa ch e t

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

8Paracetam ol 5 0 0 mg ta b le t One ta b le t

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

9A m o x ic illin 5 0 0 mg capsula One capsule

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

10M ebendazol 100 mg dew orm ing ta b le ts One ta b le t

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

I D I T E M D E S C R I P T I O N U N I T

V E N D O R 1 V E N D O R 2


C o d eP r ic e

V E N D O R C o d e IN F O R M A N TC o d e

S ee C o d e b o x # 8 S ee C o d e b o x # 8

C E R E A L S

12Rice Loose (g ra n e l)

1 Kg. r . l ^ r 1 [ ______ ] r . l ^ r 1 [ ______ ]

2 4W h ite m a ize S te w e d m a ize (pa ra m o te )

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

25O ats P ackaged

1 6 0 g r. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

P A S T A

13S p a g h e tti Loose (g ra n e l)

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

P U L S E S

26L e n tils Loose (g ra n e l)

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

M E A T

27C h icken W h o le c h ic k e n w ith m e n u d e n c ia

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

28B e e f m e a t

(c a rn e d e res)

C h e a p e s t c u t b e e f1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

29Fish ( ju re l) C h e a p e s t w h o le fre s h fish

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

30T una F lakes (N O T ch u n ks ). T in , 170 G r

1 t in r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

P O T A T O E S

11W h ite P o ta to

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

M IL K , D A IR Y P R O D U C T S A N D EG G S

16E v a p o ra te d m ilk Can / b lu e la b e l (s ta n d a rd s ize)

1 t in r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

31Eggs Loose (g ra n e l)

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

32Fresh ch eese (q u e so

fre s c o )1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

S U G A R , H O N E Y , S A L T , O IL A N D S P IC E S

17B ro w n suga r R e fin e d

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

18C o o k in g o il B o tt le d f r o m fa c to ry

1 L itre r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

33V e g e ta b le C o o k in g o il

(v e g e ta l)

B o tt le d f r o m fa c to ry1 L itre r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

19S a lt P acked , io d iz e d

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

ID ITEM DESCRIPTION U N ITVENDOR 1 VENDOR 2


C o d eP r ic e

V E N D O R C o d e IN F O R M A N TC o d eS ee C o d e b o x # 8 S ee C o d e b o x # 8

C O F F E E , T E A A N D R E F R E S H M E N T S

15N esca fe / K irm a P a cke t o f 7 g r

1 p a c k r . l ^ r 1 [ ______ ] r . l ^ r 1 [ ______ ]

3 4D a rk f iz z y d r in k o f

n a tio n a l b ra n d

P la s tic b o t t le , 5 0 0 M l1 b o tt le r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

35Coke P la s tic b o t t le , 5 0 0 M l

1 b o tt le r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

36B lo n d e /L ig h t b e e r G lass b o t t le , 6 2 5 M l

1 b o tt le r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

B R E A D A N D P A C K E D S W E E T S

37B read (pa n c o r r ie n te )

2 0 0 g r r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

38F rench to a s t (pan

fra n c e s )2 0 0 g r. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

39C ook ies (g a lle ta s de soda) 1 Package

3 4 g r. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

V E G E T A B L E S

4 0O n io n (c e b o lla de cabeza

(ro ja ))1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

41C a rro ts

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

4 2S p inach

1 Kg. r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

F R U IT S

4 3B anana (p la ta n o d e seda)

1 kg . r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

4 4Papaya

1 kg . r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

O T H E R S

4 5Basic m e n u in th e m a rk e t Lunch F or 1 person

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

20C ig a re tte s (w ith f i l t e r ) Pack o f 20

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

21D e te rg e n t (O M O ) 160 g rs

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

4 6Gas 1 c y lin d e r o f

10 kar . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

23M a tc h e s Box o f 4 0

r . l ^ r l [ ______ ] r . l ^ r l [ ______ ]

CODE BOX #8 - Vendor Codes

01 = L o c a lity sh o p (p r iv a te ) 0 6 = M e a t m a rk e t 11 = S ta te s to re 16 = N o t a v a ila b le

02 = L o c a lity co -o p 0 7 = S u p e rm a rk e t 12 = A g r ic u ltu re e x te n s io n c e n tre 17 = O th e r S p e c ify

( in th e c o r re s p o n d in g c e ll)03 = S tre e t v e n d o r 0 8 = D e p a r tm e n t s to re 13 = A g e n t o f fe r t i l is e r c o m p a n y

0 4 = M o b ile t r a d e r 0 9 = P r iv a te p h a rm a c y 14 = S u p p lie s m a rk e ts ( tu b e rs , v e g e ta b le s , m e ta , e tc .) 18 = M a rk e t S ta ll

05 = V e g e ta b le m a rk e t 10 = S ta te p h a rm a c y 15 = B o o k s to re

5.2 What are the main food items of animal kind (the main animal protein sources) for a typical local family?

(For example, milk, cheese, eggs, chicken, beef meat, pork, lam b/mutton, fish, etc.)

ID Item Price Unit of account

01 =kg, 02=unit, 03=litre, 04=O ther (Specify in the corresponding cell)

SPECACCT

ANM LFD ID ITEM PRICE SPEC A C C T AC C O U N T

1 @ [ ____ ] @ [ ]

2 @ [ ____ ] @ [ ]

3 @ [ ____ ] @ [ ]

5.3 What is the price of each of the following types of land in LOCALITY?

ID Item Average Price In case average is unknown, indicate price range if possible.

(Soles) Minimum Maximum

-77=N K -77=NK -77=NK

-88=NA -88=N A -88=NA

P R C # # # # # M IN # # # # # M A X # # # # #

5.3.1 RURAL

1 1 hectare o f irrigated land

[ ■ ] [ ■ ] [ ■ ]

2 1 hectare o f d ry land [ ■ ] [ ■ ] [ ■ ]

5.3.2 URBAN

4 1 square m eter o f land available to build a house [ ■ ] [ -------------------_ i I -------------------

5.4 If you need to buy one of the following animals how much would you pay?

ID Animal Average Price (Soles)

-77=NK

-88=NA

In case average is unknown indicate price range is possible

Minimum

-77=NK -88=N A

MIN#####

Maximum

-77=NK -88=NA

M AX#####

1 Cow (Modern Variety) [ ■ ] [ ■ ] [ ■ ]2 Cow (Traditional Variety) [ ■ ] [ ■ ] [ ■ ]3 Ox [ ■ ] [ ■ ] [ ■ ]4 Donkey [ ■ ] [ ■ ] [ ■ ]5 Mule [ ■ ] [ ■ ] [ ■ ]6 Sheep [ ■ ] [ ■ ] [ ■ ]7 Goat [ ■ ] [ ■ ] [ ■ ]8 Pig [ ■ ] [ ■ ] [ ■ ]9 Chicken [ ■ ] [ ■ ] [ ■ ]

10 Rabbit [ ■ ] [ ■ ] [ ■ ]11 Guinea Pig [ ■ ] [ ■ ] [ ■ ]

12 Llama [ ■ ] [ ■ ] [ ■ ]

13 Mixed Bull [ ■ ] [ ■ ] [ ■ ]

14 Other (Specify): _ SPOTANM L

[ ■ ]

[ ■ ] [ ■ ]

5.5 What is your best estimate of the transportation cost of bringing a 50 Kg. bag of the most important crop of this area to the most important Provincial market? (indicate crop)

CROP Average Price In case average is unknown indicate price range is possible

-77=NK Minimum Maximum

-88=NA -77=N K -88=N A -77=NK -88=NA

PRICCROP MINCROP MAXCROP

[ ] [ I [ I

5 .6 Field W o rk e r: W r ite re le v a n t o b s e rv a tio n s /c o m m e n ts in th e box b e lo w .E n t r y ID O B S E R V A T I O N S / C O M M E N T S

E N TR Y ID C O M M E N T S

1

2

3

4

5.0.2 Interview concludes: Date ____ (Day) / _____ (Month) / _____ (Day) (IN TE N D D T)

5.0.3 Interview concludes: Hour ------- • --------- (IN TE N D H )

MODULE 2 CHILD-SPECIFIC MODULE SECTION 1: EDUCATIONAL SERVICES (GENERAL)

PERSONS A N S W E R IN G TH IS SECTION (R SID ): C ode e s ta b lis h e d in In fo rm a n t R o s te r l l _ 211N F I

12__ 21IN F2

13__ 21IN F3

1 .0 In te r v ie w b e g in s : D a te _____ ( D a y ) /______ (M o n th ) / ______ (Year) (INTBEG D T

1 .0 .1 In te r v ie w b e g in s : H o u r ___ ■___ (IN TBEG H)

1 .1 F ie ld W o rk e r : N o w w e w i l l l ik e t o a sk y o u a b o u t th e e d u c a t io n a v a ila b le t o th e p e o p le in LOCALITY:

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

ID Is th e r e a c u r r e n t ly a v a ila b le in LOCALITY?

01=Y es ->S K IP t o n e x t lin e

0 0 = N o , b u t th e re is o n e in a n e a rb y lo c a lity

0 3 = N o , and th e re is n o such fa c i l i ty in a n e a rb y lo c a lity - ^ S K IP to

n e x t lin e

77=N K

A p p r o x im a te ly h o w lo n g d o e s i t ta k e t o g o f r o m th e

c e n t re o f LOCALITY t o th e n e a re s t f a c i l i t y o f th is ty p e ,

u s in g th e m o s t c o m m o n m e a n s o f t r a n s p o r ta t io n ?

W r ite d o w n N o. o f m in u te s

-77= N K

-8 8 = N A

W h a t m e a n s o f t r a n s p o r ta t io n is

c o m m o n ly u se d ?

(C ode Box # 2 )

77=N K

88= N A

# # # # # T I M S P C # # # # # # # # # # T R N

1 N u rs e ry ( e i th e r P u b lic , C o m m u n a l, o r s u p p o r te d b y a N G O ), W a w a W a s i /

C u n a M a s (D ay C are S e rv ice )

[ ______ ] [ _________ ] [ ]

22 C u n a M a s - S e rv ice o f a c c o m p a n im e n t to fa m il ie s [ ______ ] [ _________ ] [ ]

2 P r iv a te N u rs e ry [ ______ ] [ _________ ] [ ]

3 PRONOEI (N o n - fo rm a l p re s c h o o l) [ ______ ] [ _________ ] [ ]

4 N on p r iv a te P re sch o o l ( e i th e r P u b lic , C o m m u n a l, o r s u p p o r te d by a NG O ) [ ______ ] [ _________ ] [ ]

5 Fe y A le g rfa - P re sch o o l (P arish - C h u rch P u b lic S ch o o l) [ ______ ] [ _________ ] [ ]

6 P r iv a te P re sch o o l [ ______ ] [ _________ ] [ ]

7 P u b lic P r im a ry S choo l [ ______ ] [ _________ ] [ ]

8 Fe y A le g rfa - P r im a ry (P arish - C h u rch P u b lic P r im a ry S ch o o l) [ ______ ] [ _________ ] [ ]

9 O th e r P a rish -C h u rch p u b lic P r im a ry S choo l [ ______ ] [ _________ ] [ ]

10 P r iv a te P r im a ry S choo l [ ______ ] [ _________ ] [ ]

11 P u b lic S e c o n d a ry S choo l [ ______ ] [ _________ ] [ ]

12 Fe y A le g rfa - S e c o n d a ry (P a rish - C h u rch P u b lic S econd S ch o o l) [ ______ ] [ _________ ] [ ]

13 O th e r P a rish -C h u rch p u b lic S e c o n d a ry S choo l [ ______ ] [ _________ ] [ ]

14 P r iv a te S e c o n d a ry S choo l [ ______ ] [ _________ ] [ ]

20 EBA S choo l [ ______ ] [ _________ ] [ ]

15 P o s t-s e c o n d a ry te c h n o lo g ic a l in s t i tu te [ ______ ] [ _________ ] [ ]

16 U n iv e rs ity [ ______ ] [ _________ ] [ ]

21 D is ta n ce S choo l [ ______ ] [ _________ ] [ ]

17 CEOs (C e n tre s fo r O c c u p a tio n a l E d u c a tio n ) [ ______ ] [ _________ ] [ ]

18 P ost S e c o n d a ry P e d a g o g ica l In s t itu te [ ______ ] [ _________ ] [ ]

19 O th e r (S p e c ify ): [ ______ ] [ _________ ] [ ]

CODE B O X # 2 A - M eans o f T ra n s p o rta t io n

01 = By fo o t 0 5 = M o to ta x i 0 9 = T ru ck 13 = O th e r(s p e c ify in th e co rrespond ing c e ll)

02 = Anim al (ho rse donkey 0 6 = Car 10 = Rail 77=N K

03 =B icycle 0 7 = M ic ro , Combi 11 = Boat 88=N A

0 4 = M o to rcyc le 0 8 = Bus

1.2 In the past 2 years, has any Literacy activity for Adults been implemented at LOCALITY?

01= Yes 0 0 = N o (Skip to 1.4) 77=N K

[ ____ ] LTRCYCMP

1.3 Which authority was in charge of this activity? [ ____ ] TYPAUTOR

SPCTPAUT01= N a tio n a l

02= R e g io n a l/ P ro v in c ia l/ D is tr ic t le ve l (®

03= NG O

04= P arish

05= O th e r (S p e c ify ):

77= NK 88= N A

1.4 Field Worker: Write relevant observations/comments in the box below.

Entry ID OBSERVATIONS/COMMENTSPROGID PR G C M NT

1

2

3

4

1.0.2 Interview concludes: Date ____ (Day) / _____ (Month) / _____ (Day) (IN TE N D D T)

1.0.3 Interview concludes: Hour ------ : ------- (IN TE N D H )

SECTION 2: EDUCATIONAL SERVICES (PRIMARY AND SECONDARY)

Educational Center

Field Worker: The objective in this section is to gather information for a primary school and a secondary school (if also available in the community).

Give priority to the school interviewed in Round 2If the Educational Centre interviewed in Round 2 is not "Integrated", skip to Section 3.

PERSONS ANSWERING THIS SECTION (RSID): C ode e s ta b lis h e d in In fo rm a n t R o s te r l l _ 22 IN F1

2.0 Interview begins: Date _____ ( D a y ) /______ (M o n th ) / ______ (Year) (INTBEG D T

2.0.1 Interview begins: Hour ___ 1____ (IN TBEG H)

2.1 Write the Name of the Educational Centre: @ EDUCCNTR

2.1.1 Official name@ OFFCLNM

2.1.2 Educational Centre's Number (if it is a Public School) @ N U M E D U C

2.1.3 Other name (if it is known by a name, different from the official one) @ O TH R N A M E

2.1.4 Name of the locality where this centre is located (in case it is not located at LOCALITY @ LOCALITY

2.2 Fieldworker: 1 w o u ld lik e to ask y o u a b o u t th e a v e ra g e y e a r ly e x p e n d itu re p e r s tu d e n t:

(FIELDW ORKER: ask a b o u t la s t s ch o o l y e a r - 20 0 8 )

ID

Instruction Level

2.2.1 2.2.2 2.2.3 2.2.4

Registration and monthly payment

(A n n u a l to ta l)

0 0 = N o p a y m e n t is

re q u ire d

-77= N K

-8 8 = N A

APAFA (Association of Students' Parents)

0 0 = N o p a y m e n t is re q u ire d

-77= N K

-8 8 = N A

Purchase of Books, Uniform, and other supplies


-77 = N K

-8 8 = N A

Extra-ordinary Payments


-77= N K

-8 8 = N A

1 Primary [ ] [ ] [ ] [ ]

2 Secondary[ ] [ ] [ ] [ ]

3 Other: (Specify) [ ] [ ] [ ] [ ]

@ SPCLEVEL [ ] [ ] [ ] [ ]

2.3 SAY: 1 w o u ld lik e to ask y o u a b o u t c h ild re n 's a t te n d a n c e sch e d u le .

2.3.1

ID Instruction Level On average, how many hours a day do children come to class?

1 P r im a ry [ _____ ] HRSPRIM

2 S e co n d a ry [ _____ ] EDHRSSEC

3 O th e r: (S p e c ify ) VARIABLE__ [ _____ ] HRSOTHR

2.4 This Educational Centre is: 01=Y es 0 0 = N o 77=N K

2.4.1 P u b lic [ ___ ] PUBLIC

2.4.2 P riv a te [ ___ ] PRIVATE

2.4.3 P u b lic -p a r is h -c h u rc h / P a ra e s ta ta l [ ___ ] PUBCHRCH

2.4.4 C o m m u n ity [ ___ ] C O M M T Y

2.4.5 O th e r (S p e c ify ): SPECEDU [ ___ ] OTHEREDU

2.5 How many shifts does this centre have, for each instruction level?

(F o r e x a m p le : I f th e re is a d a y s h if t and an a f te rn o o n s h if t in P r im a ry o r S e c o n d a ry Leve l, m a rk "0 2 " in 2 .5 .1 o r 2 .5 .2 )

2.5.1 P r im a ry [ _____ ] SHFTPRMY

2.5.2 S e co n d a ry [ _____ ] SHFTSECD

2.5.3 O th e r (S p e c ify ): SPECSHFT [ _____ ] SHFTOTHR

2.6 What kind of educational centre is this centre? 01=Y es 0 0 = N o 77=N K

2.6.1 O ne te a c h e r fo r a ll g ra d e s (m u lt ig ra d e , o n e te a c h e r) [ _____ ] O N E4ALL

2.6.2 T w o o r m o re te a c h e rs , each w ith se ve ra l g ra d e s in th e sa m e c la s s ro o m (m u lt ig ra d e ,

se ve ra l te a c h e rs ) [ _____ ]

V 2 0 R M 0 R E

2.6.3 O ne te a c h e r p e r g ra d e [ _____ ] ONEPERGR

2.6.4 O th e r (S p e c ify ): SPECKIND [ _____ ] OTH RKND

2.7 In which language do the teachers teach? (you can choose more than one option) 01=Y es 00= Mo 77=N K

2.7.1 S pan ish [ _____ ] TCHSPAN

2.7.2 Q u e chu a [ _____ ] TCHQUE

2.7.3 A y m a ra [ _____ ] T C H A Y M A

2.7.4 O th e r n a tiv e la n g u a g e (S p e c ify ): [ _____ ] TCHSOTHR

2.8 In what language do students speak with each other at school (during breaks, or playing,)?

2.8.1 S pan ish [ _____ ] SPKSPAN

2.8.2 Q u e chu a [ _____ ] SPKQUE

2.8.3 A y m a ra [ _____ ] SPKAYM A

2.8.4 O th e r n a tiv e la n g u a g e (S p e c ify ): [ _____ ] SPKSOTHR

2.9 When did this centre start operating (year)? -77 = N K [ ____________ ] STARTOP

2.10 SAY: Now, 1 would like to ask you about students' performance last year (2008)

2.10.1 2.10.2

ID Instruction Level Last year, what was the % of students dropping out school? Last year, what was the repetition rate?

-77 = N K , -8 8 = N A -77=N K , -8 8 = N A

[ ■ 1 VARIABLE [ ____ ] VARIABLE

1 Primary [ ■ 1 PRIDROP [ ____ ] PRIM REP

2 Secondary [ ■ 1 SECDROP [ ____ ] SECREP

2.11 Does the Educational Centre have any of the following?: Is available and operative?

01=Y es 0 0 = N o 77=N K

2 .1 1 .1 C o m p u te r Lab

2 .1 1 .2 S c ience Lab (Physics, C h e m is try , B io lo g y ).

2 .1 1 .3 S p o rts F ie ld

2 .1 1 .4 L ib ra ry

2 .1 1 .5 O th e r (Specify): @ SPCINSPS

[ _____ ] LABCMPPS [ _____ ] DISLCMPS

[ _____ ] LABCCSPS [ _____ ] DISLCSPS

[ _____ ] CAM DEPPS [ _____ ] DISCDEPS

[ _____ ] BIBLITPS [ _____ ] DISBIBPS

[ _____ ] OTHINSPS [ _____ ] DISOINPS

2.12 What programs are available in the Educational Centre?

2 .1 2 .1 A PC p e r k id [ _____ ] CO M LAPPS

2 .1 2 .2 B re a k fa s t. [ _____ ] DESESCPS

2 .1 2 .3 Lunch [ _____ ] ALMESCPS

2 .1 2 .8 E d u c a tio n in te rc u ltu ra l b ilin g u e [ _____ ] TXTESCPS

2 .1 2 .6 H e a lth y , C lean a n d Safe S choo ls [ _____ ] ESCSEGPS

2 .1 2 .7 O th e r (Specify): <S> [ _____ ] OTHPROPS

2 .1 3 Does the Educational Centre have any of the following personnel? 01=Y es 0 0 = N o 77=N K

2 .1 3 .1 P sych o lo g is t [ _____ ] PSICOLPS

2 .1 3 .2 N u rse [ _____ ] ENFERMPS

2 .1 3 .3 O th e r (Specify): @ [ _____ ] OTHPERPS


Entry ID OBSERVATIONS/ COMMENTSENTRYID C O M M E N TS

1

2

3

2.0.2 Interview concludes: Date / / IN TEN D D T


2.0.3 Interview concludes: Hour ------- : --------- INTEN DH

2.15 GPS Coordinates (WGS84)of the Educational Centre where this Primary School is located (Reference Point Main Entrance to the Centre)

° . S GPSSTH

° . W GPSWEST

____________ ATTITUDE GPSALTD

Fieldworker: In the case that GPS reference point is not Main Entrance to the Centre, please write down the new reference point. REFPOINT

@

Field Worker: Once you have completed the information for both educational levels in this centre, skip to section 5 (Health Services).

SECTION 3 EDUCATIONAL SERVICES (PRIMARY)

Field Worker: Give priority to the school interviewed in Round 2

Otherwise, choose the one that receives the highest number of children and teenagers of the locality

PERSONS ANSWERING THIS SECTION (RSID): Code established in Informant Roster l l _ 23 IN F1

3.0 Interview begins: Date _____ ( D a y ) /______ (M o n th ) / ______ (Year) (IN TB EG DT

3.0.1 Interview begins: Hour ------- ■--------- (IN TBEG H)

3.1 Write the Name of the Educational Centre: ® PRIEDCNT

3 .1 .1 Official name ® PRIO FFNM

3 .1 .2 Educational Centre's Number (if it is a Public School) @ PR IN M ED C

3 .1 .3 Other name (if it is known by a name, different from the official one) @ PR IO TH N M

3 .1 .4 Name of the locality where this centre is located (in case it is not located at LOCALITY

® PRILCTLY

3.2 Fieldworker: 1 w o u ld lik e to ask y o u a b o u t th e a v e ra g e y e a r ly e x p e n d itu re p e r s tu d e n t: (FIELD W O RKER: ask a b o u t la s t sch o o l y e a r - 2 0 0 5 )

3.2.1 3.2.2 3.2.3 3.2.4

ID Instruction Level Registration and monthly payment

(A n n u a l T o ta l)

00= N o

-77= N K

-8 8 = N A

APAFA (Association of Students' Parents)


-77= N K

-8 8 = N A

Purchase of Books, Uniform, and other supplies


-77= N K

-8 8 = N A

Extra-ordinary Payments


-77= N K

-8 8 = N A

1 Primary r l PRIPRMRY r l PRIAPFPR r l PRIPRPRI f 1

f 1

PRIEXPRI

2 Other: (Specify)

PRISPLVL

r l PRIOTHER r l PRIAPFOT r l PRIPRPOTH PRIEXOTH

3 .3 SAY: 1 w o u ld lik e to ask y o u a b o u t c h ild re n 's a t te n d a n c e sch e d u le .

IDInstruction Level

3 .3 .1

On average, how many hours a day do children come to class?

77=N K 8 8 = N A

1 P r im a ry [ _____ ][ _____ ]

PRIHRSPR

2 O th e r: PRIHRSOT

3 .4 This Educational Centre is: 01=Y es 0 0 = N o 77=N K

3 .4 .1 P u b lic [ _____ ] PRIPUBLC

3 .4 .2 P riv a te [ _____ ] PRIPRVAT

3 .4 .3 P u b lic -p a r is h -c h u rc h / P a ra e s ta ta l [ _____ ] PRIPBCHR

3 .4 .4 C o m m u n ity [ _____ ] PR IC M M TY

3 .4 .5 O th e r (S p e c ify ): SPPRIED [ _____ ] PRIOTHED

3 .5 How many shifts does this centre have, for each instruction level?

(F o r e x a m p le : I f th e re is a d a y s h if t and an a f te rn o o n s h if t in P r im a ry Leve l, m a rk " 0 2 " in 3 .5 .1 )

3 .5 .1 P r im a ry [ _____ ] PRISHPRY

3 .5 .2 O th e r (S p e c ify ): SPPRISHF [ _____ ] PRISHOTH

3 .6 What kind of educational centre is this centre? 01=Y es 0 0 = N o 77=N K

3 .6 .1 O ne te a c h e r fo r a ll g ra d e s (m u lt ig ra d e , o n e te a c h e r) [ _____ ] PR IO N E4A

3 .6 .2 T w o o r m o re te a c h e rs , each w ith se ve ra l g ra d e s in th e sa m e c la s s ro o m (m u lt ig ra d e , se ve ra l te a c h e rs ) [ _____ ] P R I20M R E

3 .6 .3 O ne te a c h e r p e r g ra d e [ _____ ] PRI1PRGR

3 .6 .4 O th e r (S p e c ify ): SPPRIKND [ _____ ] PRIOTHKN

3 .7 In what language do the teachers teach? (you can choose more than one option) 01=Y es 0 0 = N o 77=N K

3 .7 .1 S pan ish [ _____ ] PRITCHSP

3 .7 .2 Q u e chu a [ _____ ] PRITCHQU

3 .7 .3 A y m a ra [ _____ ] PRITCHAM

3 .7 .4 O th e r n a tiv e la n g u a g e (S p e c ify ): PRIOTHTC [ _____ ] PRITCHOT

3 .8 In what language do students speak with each other at school (during breaks, when playing,..)?

01=Y es 0 0 = N o 77=N K

3 .8 .1 S pan ish [ _____ ] PRISPKSP

3 .8 .2 Q u e chu a [ _____ ] PRISPKQU

3 .8 .3 A y m a ra [ _____ ] PRISPKAM

3 .8 .4 O th e r n a tiv e la n g u a g e (S p e c ify ): SPPRISPK [ _____ ] PRISPKOT

3.9 When did this centre start operating (year)? -77= N K ________ PRISTROP

3.10 SAY: Now, 1 would like to ask you about students' performance last year (2012).

3.10.1 3.10.2


-77 = N K , -88 = N A , -77= N K , -88 = N A ,

f • 1 VARIABLE [ • 1 VARIABLE

1 Primary f • 1 PRIDROP [ • 1 PRIM REP

3 .1 1 D oes th e E d u c a t io n a l C e n tre h a v e a n y o f th e fo l lo w in g ? : 01=Y es 0 0 = N o 77=N K Is a v a ila b le a n d o p e ra t iv e ?

01=Y es 0 0 = N o 77=N K

3 .1 1 .1 C o m p u te r Lab [ _____ ] PRILBCMP [ _____ ] PRIDCMPS

3 .1 1 .2 S c ience Lab (Physics, C h e m is try , B io lo g y ). [ _____ ] PRILBCCS [ _____ ] PRIDCSPS

3 .1 1 .3 S p o rts F ie ld [ _____ ] PRICM DEP [ _____ ] PRIDDEPS

3 .1 1 .4 L ib ra ry [ _____ ] PRIBBLIT [ _____ ] PRIDSBPS

3 .1 1 .5 O th e r (S p e c ify ) : @ [ _____ ] PRIOTHIN [ _____ ] PRIDSONP

3 .1 2 W h a t p ro g ra m s a re a v a ila b le in th e E d u c a t io n a l C e n tre ? 01=Y es 0 0 = N o 77=N K

3 .1 2 .1 A PC p e r k id [ _____ ] PRICMLPS

3 .1 2 .2 B re a k fa s t. [ _____ ] PRIDSSCP

3 .1 2 .3 Lunch [ _____ ] PRIALMSC

3 .1 2 .8 E d u c a tio n in te rc u ltu ra l b ilin g u e [ _____ ] PRITXTES

3 .1 2 .6 H e a lth y , C lean a n d S a fe S c h o o ls [ _____ ] PRIESCSG

3 .1 2 .7 O th e r (S p e c ify ) : <S> [ _____ ] PRIOTRPS

3 .1 3 D oes th e E d u c a tio n a l C e n tre h a ve a n y o f th e fo l lo w in g p e rs o n n e l?

01=Y es 0 0 = N o 77=N K

3 .1 3 .1 P sych o lo g is t ___ PRIPSICL

3 .1 3 .2 N u rse ___ PRIENFRM

3 .1 3 .3 O th e r (S p e c ify ) : @ SPPRIPER ___ PRIOTPER


Entry ID OBSERVATIONS/COMMENTSENTRYID C O M M E N TS

1

2

3



3.0.3 Interview concludes: Hour ------ : ------- INTENDH


° . S GPSSTH

° . W GPSWEST

____________ ATTITUDE GPSALTD

Fieldworker: In the case that GPS reference point is not Main Entrance to the Centre, please write down the new reference point. REFPOINT

@

SECTION 4 EDUCATIONAL SERVICES (SECONDARY)

Fieldworker: Give priority to the school interviewed in Round 2

Otherwise, choose the one that receives the highest number of teenagers of the locality

PERSONS ANSWERING THIS SECTION (RSID): C ode e s ta b lis h e d in In fo rm a n t

R o s te r

l l _

24 IN F1

4.0 Interview begins: Date _____ ( D a y ) /______ (M o n th ) / ______ (Year) (IN TB EG DT

4.0.1 Interview begins: Hour --------- ■----------- (IN TBEG H)

4.1 Write the Name of the Educational Centre: ® PREEDCNT

4.1.1 O ffic ia l n a m e ® PREOFFNM

4.1.2 E d u c a tio n a l C e n tre 's N u m b e r ( i f i t is a P u b lic S ch o o l) @ PRENM EDC

4.1.3 O th e r n a m e ( i f i t is k n o w n b y a n a m e , d if fe re n t f r o m th e o f f ic ia l o n e ) @ PREO THNM

4.1.4 N a m e o f th e lo c a lity w h e re th is c e n tre is lo c a te d ( in case it is n o t lo c a te d a t @ PRELCTLY

4.2 Fieldworker: 1 w o u ld lik e to ask y o u a b o u t th e a v e ra g e y e a r ly e x p e n d itu re p e r s tu d e n t: (FIELD W O RKER: ask a b o u t la s t sch o o l y e a r - 2 0 0 8 )

4.2.1 4.2.2 4.2.3 4.2.4

ID Instruction Level Registration and monthly payment APAFA (Association of Students' Parents) Purchase of Books, Uniform, and other supplies Extra-ordinary Payments

(A n n u a l T o ta l)

00= N o

-77= N K

-8 8 = N A


-77= N K

-8 8 = N A


-77= N K

-8 8 = N A


-77= N K

-8 8 = N A

1 Secondary [ ___ ] SECNDRY [ ___ ] APAFASEC [ ___ ] PURSEC [ ___ ] EXTRSEC

4 .3 SAY: 1 w o u ld lik e to ask y o u a b o u t c h ild re n 's a t te n d a n c e sch e d u le .

IDInstruction Level

4 .3 .1

On average, how many hours a day do children come to class? 77=N K 88= NA

1 S e co n d a ry [ ______ ] HRSSECN

4 .4 T h is E d u c a t io n a l C e n tre is: 01=Y es 0 0 = N o 77=N K

4 .4 .1 P u b lic [ _____ ] PREPUBLC

4 .4 .2 P riv a te [ _____ ] PREPRVAT

4 .4 .3 P u b lic -p a r is h -c h u rc h / P a ra e s ta ta l [ _____ ] PREPBCHR

4 .4 .4 C o m m u n ity [ _____ ] PR ECM M TY

4 .4 .5 O th e r SPPREED [ _____ ] PREOTHED

4 .5 H o w m a n y s h if ts d o e s th is c e n t re h a v e , f o r e a c h in s t ru c t io n le v e l?

(F o r e x a m p le : I f th e re is a d a y s h if t and an a f te rn o o n s h if t in S e c o n d a ry Leve l, m a rk " 0 2 " in 4 .5 .1 )

4 .5 .1 S e co n d a ry [ _____ ] SHFTSECD

4 .6 W h a t k in d o f e d u c a t io n a l c e n t re is th is c e n tre ? 01=Y es 0 0 = N o 77=N K

4 .6 .1 O ne te a c h e r fo r a ll g ra d e s (m u lt ig ra d e , o n e te a c h e r) [ _____ ] PREONE4A

4 .6 .2 T w o o r m o re te a c h e rs , each w ith se ve ra l g ra d e s in th e sa m e c la s s ro o m (m u lt ig ra d e , se ve ra l te a c h e rs ) [ _____ ] P R E 20M R E

4 .6 .3 O ne te a c h e r p e r g ra d e [ _____ ] PRE1PRGR

4 .6 .4 O th e r (S p e c ify ): SPPREKND [ _____ ] PREOTHKN

4 .7 In w h a t la n g u a g e d o th e te a c h e rs te a c h ? (y o u c a n c h o o s e m o re th a n o n e o p t io n ) 01=Y es 0 0 = N o 77=N K

4 .7 .1 S pan ish [ _____ ] PRETCHSP

4 .7 .2 Q u e chu a [ _____ ] PRETCHQU

4 .7 .3 A y m a ra [ _____ ] PRETCHAM

4 .7 .4 O th e r n a tiv e la n g u a g e (S p e c ify ): [ _____ ] PRETCHOT

4 .8 In w h a t la n g u a g e d o s tu d e n ts s p e a k w i t h e a c h o th e r a t s c h o o l ( d u r in g b re a k s , w h e n p la y in g , e tc .)?

4 .8 .1 S pan ish [ _____ ] PRESPKSP

4 .8 .2 Q u e chu a [ _____ ] PRESPKQU

4 .8 .3 A y m a ra [ _____ ] PRESPKAM

4 .8 .4 O th e r n a tiv e la n g u a g e (S p e c ify ): SPPRESPK [ _____ ] PRESPKOT

4 .9 W h e n d id th is c e n tre s ta r t o p e ra t in g (y e a r)? -77 = N K ____________ PRESTROP

4.10 SAY: Now, 1 would like to ask you about students' performance last year (2012)

4.10.1 4.10.2


-77 = N K , -88= N A , -77= N K , -88 = N A ,

f • 1 VARIABLE [ • 1 VARIABLE

1 Secondary [ • ] SECDROP [ • J SECREP

4 .1 1 D oes th e E d u c a t io n a l C e n tre h a v e a n y o f th e fo l lo w in g ? :

01=Y es 0 0 = N o 77=N K

4 .1 1 .1 C o m p u te r Lab [ _____ ] PRELBCMP [ _____ ] PREDCMPS

4 .1 1 .2 S c ience Lab (Physics, C h e m is try , B io lo g y ). [ _____ ] PRELBCCS [ _____ ] PREDCSPS

4 .1 1 .3 S p o rts F ie ld [ _____ ] PRECMDEP [ _____ ] PREDDEPS

4 .1 1 .4 L ib ra ry [ _____ ] PREBBLIT [ _____ ] PREDSBPS

4 .1 1 .5 O th e r (S p e c ify ): @ [ _____ ] PREOTHIN [ _____ ] PREDSONP

4 .1 2 W h a t p ro g ra m s a re a v a ila b le in th e E d u c a t io n a l C e n tre ?

01=Y es 0 0 = N o 77=N K

4 .1 2 .1 A PC p e r k id [ _____ ] PRECMLPS

4 .1 2 .2 B re a k fa s t. [ _____ ] PREDSSCP

4 .1 2 .3 Lunch [ _____ ] PREALMSC

4 .1 2 .4 B il in g u a l In te rc u ltu ra l E d u c a tio n [ _____ ] PRETXTES

4 .1 2 .5 H e a lth y , C lean a n d Safe S choo ls [ _____ ] PREESCSG

4 .1 2 .6 O th e r (S p e c ify ): <S> SPPRECOT [ _____ ] PREOTRPS

4 .1 3 D oes th e E d u c a t io n a l C e n tre h a v e a n y o f th e fo l lo w in g p e rs o n n e l?

01=Y es 0 0 = N o 77=N K

4 .1 3 .1 P sych o lo g is t [ _____ ] PREPSICL

4 .1 3 .2 N u rse [ _____ ] PREENFRM

4 .1 3 .3 O th e r (S o e c ifv ): <S> SPPREPER [ _____ ] PREOTPER



1

2

3

4.0.2 Interview concludes: Date / /(Day) (Month) (Year)

IN TEN D D T

4.0.3 Interview concludes: Hour ------- : --------- INTENDH


° . S PREGPSSH

° . W PREGPSWS

____________ ALTITUDE PREGPSAL

Fieldworker: In the case that GPS reference point is not Main Entrance to the Centre, please write down the new reference point. PRERFPNT

Fieldworker: Once you have completed the information for both educational levels (Section 3 and 4), skip to section 5 (Health Services).

SECTION 5 HEALTH SERVICES

PERSONS ANSWERING THIS SECTION (RSID): C ode e s ta b lis h e d in In fo rm a n t R o s te r 11 _ 25 IN F1

5 .0 Interview begins: Date _____ ( D a y ) /______ (M o n th ) / ______ (Year) INTBEG DT

5 .0 .1 Interview begins: Hour --------- ■----------- (IN TBEG H)

ID

1

2

3

4

5

6

7

8

9

10

11

12

5.1 Field Worker: Let me ask you some questions regarding the different health facilities available to LOCALITY:

5.1.1

Is there a _________ c u r re n t ly a v a ila b le in LOCALITY

01=Y es-> SKIP TO n e x t lin e

0 0 = N o , b u t th e re is o n e in a n e a rb y lo c a lity (go to 5 .1 .2 )

0 3 = No, a n d th e re is n o such fa c i l i ty in a n e a rb y lo c a l i t y ^ SKIP TO n e x t lin e

77=N K

5.1.2 5.1.3

Approximately how long does it take to go from the centre of LOCALITY to the nearest facility of this type, using the most common means of transportation? (in m in u te s )

What means of transportation is commonly used?(C ode B ox # 2A )

P u b lic H o s p ita l

ESSALUD H o s p ita l

P r iv a te H o s p ita l /C lin ic

S ta te ru n H e a lth C e n tre

H e a lth C e n tre ESSALUD

P riv a te H e a lth C e n tre

P u b lic d is p e n s a ry

P r iv a te D o c to r 's O ff ic e

D e liv e ry C lin ic (P r iv a te )

P h a rm a cy

B ir th C o n tro l / F e r t i l i ty C lin ic

O th e r SPECFAC

PBHSPCUR

ESSHSPCR

PVHSPCUR

STHLTCUR

ESLCNTCR

HTLCRCUR

PBDSPCUR

PVDOCCUR

DLVRYCUR

PH ARM CUR

FRTLYCUR

OTFACCUR

PBHSPTIM

ESSHSPTM

PVHSPTIM

STHLTTIM

ESSCNRTM

HTLCRTIM

PBDSPTIM

DOCTRTIM

DLVRYTIM

P H A R M T IM

FRTLYTIM

OTFACTIM

[ ________ ] PBHSPTRN

SPCPBHSP

[____ ]SPCESSHP

[ ____ ]SPCPVH

[ ____ ]SPCSTHL

[ ____ ]SPCESSHL

[ ____ ]SPCHTLC

[ ____ ]SPCPBBDS

[ ____ ]SPCDCTR

[____ ]SPCDLVR

[ ____ ]SPCPHAR

[ ____ ]SPCFRTL

[ ____ ]SPCOTFAC

CODE BOX # 2 A - Means of Transportation

01 = By fo o t 0 5 = M o to ta x i 0 9 = T ru c k 13 = O th e r(s p e c ify in th e c o rre s p o n d in g c e ll)

02 = A n im a l ( h o rs e / d o n k e y ) 0 6 = Car 10 = Rail 77=N K

03 = B icyc le 0 7 = M ic ro , C o m b i 11 = B o a t

0 4 = M o to rc y c le 0 8 = Bus

5.2 Which of the following health personnel exist and deliver their services in LOCALITY: 01=Y es 0 0 = N o 8 8 = N A 77=N K

5.2.1 T ra in e d m id w ife [ ___ ] M ID W IF E

5.2.2 T ra d it io n a l b ir th a t te n d a n t [ ___ ] B IRTHATT

5.2.3 T ra d it io n a l h e a le r [ ___ ] TRADHLR

5.2.4 C u rio so [ ___ ] CURIOSO

5.2.5 V illa g e h e a lth w o rk e r [ ___ ] V ILH T H W K

5.2.6 A u x ilia r ie s /T e c h n ic ia n n u rs e s /M e d ic a l c a re a ss is ta n t [ ___ ] AU X ILIAR

5.2.7 N urse [ ___ ] NURSE

5.2.8 S ocia l W o rk e r [ ___ ] SOCW RKR

5.2.9 M e n ta l h e a lth w o rk e r [ ___ ] M TLHLTH

5.2.10 G e n e ra l P h ys ic ia n [ ___ ] GENPHYS

5.2.11 S p e c ia lis t P h ys ic ia n (p a e d ia tr ic ia n , g y n a e c o lo g is t, p s y c h ia tr is t, e tc .) [ ___ ] SPECPHYS

5.2.12 A n e s te s is t [ ___ ] ANESTST

5.2.13 D e n tis t [ ___ ] DENTIST

5.2.14 B lo o d B ank [ ___ ] BLO O D BNK

5.2.15 O th e r (S p e c ify ): SPECPERS [ ___ ] OTHRPERS

5.3 Has there been any nutritional training to members of LOCALITY during the last 6 months? 01=Y es 0 0 = N o 77=N K [ ___ ] NTRLTRNG



1

2

3

4

5



IN TEN D D T

5.0.3 Interview concludes: Hour ------ : ------- INTENDH

Key Health Facility Available in LOCALITY

PERSONS ANSWERING THIS SECTION (RSID): Code established in

Informant Roster

1 1 ____ 2KINF1

5.0.4 Interview begins: Date / /(Day) (Month) (Year)

INTBEG DT

5.0.5 Interview begins: Hour ____ • _____ INTBEGH

5.5.1 Write the Name of this Health Establishment: @ HLTHEST

5.5.2 Name of the locality where this center is located (in the case it is not located at LOCALITY) @

LOCLTY

Characteristics of this Health Establishment

5.6 What type of Health Establishment is this health facility?

01 = P u b lic 0 2 = P riv a te

03 = O th e r (Specifv): (®

[ ___ ] TYPESTB

5.7 What type of Health Services does this facility deliver (can mark more than one)?

01 = P re v e n tio n 0 2 = P r im a ry h e a lth 03 = H o s p ita l S e rv ices

0 4 = O th e rs (S p e c ify ) (W RITE THE ANSW ER A N D THEN CODIFY)

[ ___ ] TYPEDLV1

[ ___ ] TYPEDLV2

[ ___ ] TYPEDLV3

5 .8 5 .8 .1 5 .8 .2

ID E q u ip m e n t D oes th is fa c i l i t y h a v e th is t y p e o f e q u ip m e n t?

01=Yes

0 0 = N o -> sk ip to n e x t lin e

77=N K

D oes i t w o r k p ro p e r ly ?

01 = F u n c tio n s a d e q u a te ly

0 2 = W ith s o m e lim ita t io n s

0 3 = W ith g re a t l im ita t io n s

0 4 = D oes n o t w o rk a t all

77=N K 8 8 = N A

1 E le c tro c a rd io g ra p h [ ______ ] ELCTROCR [ ______ ] ELECTWRK

2 X -rays e q u ip m e n t [ ______ ] XRAYEQUP [ ______ ] XRAYW RK

3 E co g ra ph [ ______ ] ECOGRPH [ ______ ] ECOGRW RK

4 S te r il iz e r [ ______ ] STRLZER [ ______ ] STRLZWRK

5 M a m m o g ra m e q u ip m e n t [ ______ ] M A M M O G R M [ ______ ] M A M M O W R K

6 A n g io g ra p h [ ______ ] AN G IO G R [ ______ ] A N G IO W R K

7 T o m o g ra p h y [ ______ ] TO M O G R P H [ ______ ] T O M O W R K

8 R e fr ig e ra to r c a b in e t [ ______ ] REFRIGER [ ______ ] REFRGWRK

9 C u ltu re in c u b a to r [ ______ ] CULTRINC [ ______ ] CLTRWRK

10 M ic ro s c o p e [ ______ ] MICROSCP [ ______ ] M IC R O W R K

11 In c u b a to r fo r N e w -b o rn s [ ______ ] INCUBATR [ ______ ] INC UBW R K

12 M o n ito r o f v ita l fu n c t io n s [ ______ ] M O N TR V TL [ ______ ] VTLFCW RK

13 D e f ib r i l la to r [ ______ ] DESFIBTR [ ______ ] DESFBWRK

14 C lo th e s and bas ic im p le m e n ts fo r S u rg ica l P ro c e d u re s [ ______ ] BS C IM P LM [ ______ ] BSCIM W RK

15 A n a e s th e s ia m a c h in e [ ______ ] ANESTHIA [ ______ ] ANESTW RK

16 O xyg e n s u p p lie s (o xyg e n c y l in d e rs , ..) [ ______ ] OXYGENSP [ ______ ] OXYGNW RK

17 S p iro m e te r [ ______ ] ESPIRMTR [ ______ ] ESPIRWRK

18 D e n ta l a rm c h a ir [ ______ ] DENTAL [ ______ ] DNTLW RK

19 O th e r (S p e c ify ): [ ______ ] OTHREQP1 [ ______ ] O TH RW RK1

20 O th e r (S p e c ify ): [ ______ ] O THREQP2 [ ______ ] O TH RW R K2

5.9 Does this health facility have a transportation unit in working condition?

01=Y es 0 0 = N o , 77=N K ( g o to 5 .11 ) [ _____ ]

TRNSPRTN

5.10 How many transportation units does this centre have? -77 = N K -8 8 = N A

5.10.1 A m b u la n c e [ _____ ] A M BLN C E

5.10.2 T ru c k [ _____ ] TRUCK

5.10.3 Car [ _____ ] CAR

5.10.4 M o to ta x i [ _____ ] M O TO TA XI

5.10.5 O th e r (S p e c ify ): @ SPECTRNS [ _____ ] OTHRTRNS

5.11 Does this Health facility have beds and/or trollies?

01=Y es 0 0 = N o , 77=N K (go to 5 .1 3 ) [ _____ ]

BEDS

5.12 How many?

-7 7 = N K -8 8 = N A [ _____ ]

N U M B E D S

5.13 Do health workers provide extramural services?

01=Y es 0 0 = N o , 77=N K ( g o to 5 .1 5 ) [ _____ ]

XTRM LSRV

5.14

ID What type of Services?

SERVID TYPESERV

1

2

3

4

5

6

7

8

5.15 5.15.1 5.15.2

ID In relation to the operation hours /schedule of the Health Center: Number of days of the week when it is open Hours per day( fo r e x a m p le , f r o m 9 a m to 1 p m & 2 p m to 6 p m )

1 H e a lth C e n tre (m a in o ff ic e )

@

HLTHDYS

@

HLTHHRS

2 E m e rg e n cy

@

EMRGYDYS

@

EMRGYHRS

3 E x te rn a l c o n s u lta n ts ( i f i t is a H o s p ita l)

@

EXTRNDYS

@

EXTRNHRS

4 O th e r (s p e c ify ): VARIABLE

@

OTHRDYS OTHRHRS

@

5.16 Characteristics of the health centre

(Professional / Non Professional)

5.16.1 5.16.2

Permanent Staff

Indicate the number of people who work full time in the health centre

What language(s) do the staff uses to communicate with the patients? (you can choose more than one option)

01=S pan ish

0 2 = Q u e ch u a

0 3 = A y m a ra

0 4 = O th e r n a tiv e la n g u a g e

(s p e c ify in c o rre s p o n d in g c e ll)

88=N A

1. G e n e ra l d o c to r [ ______ ]

GNRDCFLL

[ 1 @

[ ] @ G N R D LN G 1, G N R D LN G 2

2a. S p e c ia lize d d o c to r . In d ic a te th e s p e c ia lity :

<S> SPCFLL1[ ______ ]

DOCSPEC1

[ 1 @

[ ] @ SPCLNG11, SPCLNG12

2b. S p e c ia lize d d o c to r . In d ic a te th e s p e c ia lity :

<S> SPCFLL2[ ______ ]

DOCSPEC2

[ 1 @

[ ] @ SPCLNG21, SPCLNG22

3. D e n ta l s u rg e o n /D e n t is t [ ______ ]

DNTLFLL

[ 1 @

[ ] @ D NTLLN G 1, DN TLLN G 2

4. M id w ife [ ______ ]

M ID W FF LL

[ 1 @

[ ] @ M ID W F L N G 1 , M ID W F L N G 2

5. O p h ta lm o lo g is t [ ______ ]

OPHTHFLL

[ 1 @

[ ] @ O PHTLN G 1, O PH TLN G 2

6. N u rses [ ______ ]

NURSEFLL

[ 1 @

[ ] @ NRSELNG1, NRSELNG2

7. A u x il ia ry /T e c h n ic ia n n u rs e s /M e d ic a l ca re

a ss is ta n t[ ______ ]

AUXLRFLL

[ 1 @

[ ] @ AXLRLNG 1, AXLRLNG2

8. P h a rm a c is t [ ______ ]

PH ARM FLL

[ 1 @

[ ] @ P H R M LN G 1, P H R M LN G 2

9. N u t r i t io n is t [ ______ ]

NUTRCFLL

[ 1 @

[ ] @ NTRCLNG1, NTRCLNG1

10. P sych o lo g is t [ ______ ]

PSYCH FLL

[ 1 @

[ ] @ PSYCLNG1, PSYCLNG2

11. S ocia l W o rk e r [ ______ ]

SOCLFLL

[ 1@

[ ] @ SOCLLNG1, SOCLLNG2

12. B io lo g is t/C h e m is t [ ______ ]

BIOLGFLL

[ 1@

[ ] @ B IO LLNG 1, B IO LLNG 2

13. R a d io lo g is t [ ______ ]

RADIOFLL

[ 1@

[ ] @ R AD ILN G 1, R AD ILNG 2

14. O b s te tr ic ia n [ ______ ]

OBSTRFLL

[ 1@

[ ] @ OBSTLNG1, OBSTLNG2

15. O th e r (S p e c ify ) <S> SPECFULL [ ______ ]

OTHERFLL

[ 1@

[ ] @ O TH RLN G 1, O TH RLN G2


OTHRFLL2

[ 1@

[ ] @


OTHRFLL3

[ 1@

[ ] @

5.17 5.17.1 Does this health center refer cases of child or adolescent abuse to any organization?

01=Y es 0 0 = N o , 77=N K ( g o to 5 .1 8 ) [ _____ ]

ABUSE

5.17.2 What organization is that?

@

ABUSEORG

5.18 5.18.1 Does this health center refer cases of family violence to any organization?

01=Y es 0 0 = N o , 77=N K (go to 5 .1 9 ) [ _____ ]

FM LYVLNC

5.18.2 What organization is that?

@

VLNCORG

5.19 Since what year has the health centre existed? -77= N K [ _____ ] EXIST

5.20 Has this health centre changed status (for example, from health centre to hospital), in that case, indicate the status change and the year when it occurred ) CNTRCHNG

@

5.21 Areas of Influence of this health facility: Could you tell me what are the localities most of the patients come from (live in)?

( ra n k th e lo c a lit ie s f r o m th e m o s t im p o r ta n t to th e le a s t im p o r ta n t)

5.21.1 5.21.2 5.21.3 5.21.4 5.21.5

Write the name of the Code of the locality Code of the route of access What is the means of transportation most used by patients to Approximately, how long does itlocality the patients get to this health facility? take for the patients to arrive to thiscome from. health facility?

ID (C ode Box # 9) (C ode Box # 10) (C ode B ox # 2) -77= N K

77=N K (in m in u te s )

LOCLTYID N AM ELC LT CODE ROUTE TRNSPTNT TIM E A R R V

SPECCODE SPECRTE SPECTRNS

1 @ r i @ [ 1@ r i @ [ _________]

2 @ r i @ [ 1@ r i @ [ _________]

3 @ r i @ [ 1@ r i @ [ _________]

4 @ r i @ [ 1@ r i @ [ _________]

5 @ [ ]@ [ ]@ [ ]@ [ _________]

CODE BOX # 09 - Locality

0 1 = T o w n 0 4 = P e a sa n ts ' C o m m u n ity

0 2 = V illa g e 05=U A -C A P

0 3 = A n n e x 0 6 = O th e r (s p e c ify in th e c o rre s p o n d in g c e ll)

CODE BOX # 10 - Routes of Access

01= P aved ro a d o r u n p a v e d -e n g in e e re d e a rth ro a d 0 4 = R iv e r / la k e

02= M o to r iz e d u n p a v e d ro a d s /tra c k s 0 5 = O th e r (s p e c ify in th e c o r re s p o n d in g c e ll)

03= N o n m o to r iz e d u n p a v e d ro a d s /tra c k

5.22 Field Worker: Write relevant observations/comments on the shortage of supplies to assist medical problems affecting children and adolescents. For instance, abortions and illegal drugs related problems

OBSERVATIONS/COMMENTSEntry ID

ENTRYID C O M M E N TS

1

2

3

4

5

5 .0 .2 Interview / /(Day) (Month) (Year)

IN TEN D D T

5 .0 .3 Interview ------ : ------- INTENDH

Field Worker: Observation Guide (Health Centre)5.23 Of what is the wall of this health facility made? [ _____ ] W A LLH T

01 = A d o b e 0 2 = Q u in c h a 03 = W o o d

0 4 = B r ic k /c o n c re te 0 5 = O th e r (S p e c ify ) VARIABLE

5.24 Field Worker: Indicate the preservation status of the building

01 = G o o d 0 2 = R e g u la r 0 3 = D a m ag e d

[ _____ ]

STSBLDHT

5.25 Field Worker: In which condition is the building where the centre functions?

0 0 = N o 01=Y es 77=N K

5.30.1 A p p ro p r ia te [ _____ ]

[ _____ ]

[ _____ ]

[ _____ ]

[ _____ ]

CNDAPP

5.30.2 In s u f f ic ie n t space CNDINSFF

5.30.3 In a p p ro p r ia te lig h t in g CNDLG HT

5.30.4 In a p p ro p r ia te v e n t i la t io n C NDVNTL

5.30.5 P o o r d is t r ib u t io n o f space CNDSPACE

5.30.6 O th e r (S p e c ify ) SPECCOND [ _____ ] O THRCOND

5.26 Field Worker: Regarding the public utilities available to this Health facility

5.26.1 5.26.2 5.26.3 5.26.4

IDSource of water

The centre's source of water is:

01=Y es 0 0 = No

77=N K

If is NO o NK skip a next line

On average, How many hours per day is there access to water?

77=N K

88 = N A

How many days per week?

77=N K

88 = N A

What is its functioning status? (in terms of whether it works, how clean it is, and so on)

0 1 = G o o d

0 2 = R e g u la r

03=B ad

77=N K 8 8 = N A

1 P iped in to d w e l l in g /y a rd /p lo t (p u b lic ) [ ______ ] DWELLSRC DW ELLHRS DWELLDYS DWELLSTS

2 O th e r: (sp e c ify ) [ ______ ] OTHRSRC

5.27 5.27.1 5.27.2

ID

Sewage service

Where do people in the centre relieve themselves/do their business/defecate?

01=Y es

0 0 = N o (go to n e x t lin e )

What is the functioning status of this service? (in terms of whether it works, how clean it is, and so on)

0 1 = G o o d 0 2 = R e g u la r 0 3=B ad

77=N K 88 = N A

1 F lush t o i le t w ith in th e H e a lth C e n tre c o n n e c te d to a p ip e o r s e p tic ta n k [ ______ ] TOILINOB [ ______ Jt l t in s t s

2 F lush t o i le t o u ts id e th e H e a lth C e n tre c o n n e c te d to a p ip e o r s e p tic ta n k [ ______ ] TLTOUTOB [ ______ Jt l o u t s t s

3 P it la t r in e in s id e th e fa c i l i ty , used e x c lu s iv e ly b y th e H e a lth C e n tre [ ______ ] PITLATIN [ ______ ] PITINSTS

4 P it la t r in e o u ts id e th e fa c i l i ty , used e x c lu s iv e ly b y th e H e a lth C e n tre [ ______ ] PITLTOUT [ ______ ]PTOUTSTS

5 P it la t r in e o f c o m m o n use (used by v illa g e rs ) [ ______ ] ANYPITHT [ ______ Ja n y p t s t s

6 M o u n ta in , o p e n f ie ld , fo re s t [ ______ ] HILLHT

7 R ive r, s tre a m , cana l [ ______ ] RIVERHT

8 O th e r (s p e c ify ) [ _____ ] OTHRSRVC SRVCSTS

5.28 What is the centre source of electricity?

01= P u b lic c o n n e c t io n 02 = E le c tr ic ity G e n e ra to r Set 0 3 = D o n o t have [ _____ ]

04= O th e r (S p e c ify ) SPCELCHT ELCTRHT

5.29 Is this the same Health Centre interviewed in Round 3? [ _____ ]

01=Y es 00= N o SAMESTR2

5.30 GPS Coordinates (WGS84) of the Health Centre (Reference Point Main Entrance to the Centre)

° . S GPSSTHHT

° . W GPSW STHT

____________ ALTITUDE GPSALTHT

Fieldworker: In the case that GPS reference point is not Main Entrance to the Centre, please write down the new reference point. REFPNTHT

@

SECTION 6 CHILD AND ADOLESCENT PROTECTION SERVICES

PERSONS ANSWERING THIS SECTION (RSID): C ode e s ta b lis h e d in In fo rm a n t R o s te r l l _ 26 IN F1

12__ 26 IN F 2

13__ 26 IN F 3

6 .0 Interview begins: Date _____ ( D a y ) /______ (M o n th ) / ______ (Year) (IN TB EG DT

6 .0 .1 Interview begins: Hour --------- * ----------- (IN TBEG H)

6.1 djs th e r e a n v o rg a n iz a t io n t h a t re c e iv e s e p o r ts o f cases o f c h ild 's r ig h ts v io la t io n a t LOCALITY, su c h as p h y s ic a l v io le n c e , s e x u a l a b u s e , u n re c o g n iz e d c h ild , p ro b le m s

w i t h p a y m e n t o f c h ild s u p p o r t?

01=Y es 0 0 = N o 77=N K [ _____ ]

CHORGACC

6.2 .■ N o rm a lly , w h a t in s t i t u t io n /o r g a n iz a t io n /o e r s o n a t LOCALITY re c e iv e s a n d ta k e s c a re o f th e s e re p o r ts ?

01=Y es 0 0 = N o 77=N K

6 .2 .1 P o lice S ta t io n ( re g u la r) [ _____ ] CHPOLICE

6 .2 .2 P o lice S ta t io n S p e c ia lize d in W o m e n Cases [ _____ ] C H P LC W M N

6 .2 .3 H e a lth C e n tre [ _____ ] CHHEALTH

6 .2 .4 D is tr ic t o r P ro v in c e D E M U N A (M u n ic ip a l O m b u d s m a n O ff ic e fo r th e C h ild and A d o le s c e n t) [ _____ ] C H D E M U N A

6 .2 .5 P a rrish -C h u rch D N A (O m b u d s m a n O ff ic e fo r th e C h ild a n d A d o le s c e n t) [ _____ ] CHCHRDNA

6 .2 .6 C o m m u n ity D N A [ _____ ] C H C M TD N A

6 .2 .7 N G O DN A [ _____ ] C H N G O D N A

6 .2 .8 T o w n D N A [ _____ ] C H T W N D N A

6 .2 .9 S choo l D N A [ _____ ] CHSCHDNA

6 .2 .1 0 O th e r ty p e o f D N A [ _____ ] C H O TH D N A

6 .2 .1 1 S choo l [ _____ ] CHSCHOOL

6 .2 .1 2 P a rrish - C h u rch [ _____ ] CHPARCHR

6 .2 .1 3 N o th ir d p a r ty ta k e s p a r t o f th is , I t is ju s t d e a lt w ith W ith in th e fa m ily o r w ith c lo se fr ie n d s [ _____ ] C H IN FM LY

6 .2 .1 4 C o m m u n a l A u th o r i t ie s

[ _____ ]

C HAU TCO M

6 .2 .1 5 N G O (S p e c ify ):

@

SPCHNGO

[ _____ ]

CHNG O O TH

6 .2 .1 6 O th e r CHSPCOR1 [ _____ ] CHOTHOR1

6 .2 .1 7 O th e r CHSPCOR2 [ _____ ] CHOTHOR2

6 .1 2 .1 8 O th e r CHSPCOR3 [ _____ ] CHOTHOR3

6.3 Is there anv organization that receivesreports of cases of Female Adults' rights violation at LOCALITY, such as physical violencia and sexual abuse?

01=Y es 0 0 = N o 77=N K [ _____ ]

W M O R G A C C

6.4 i Normally, what institution/organization/person at LOCALITY receives and takes care of these reports?

01=Y es 0 0 = N o 77=N K

6.4.1 P o lice S ta t io n ( re g u la r) [ _____ ] W M P O LIC E

6.4.2 P o lice S ta t io n S p e c ia lize d in W o m e n Cases [ _____ ] W M P L C W M N

6.4.3 H e a lth C e n tre [ _____ ] W M HEALTH

6.4.4 CEM (C e n tre fo r W o m e n E m e rg e n c ie s ) [ _____ ] W M C E M

6.4.5 S choo l [ _____ ] W M S C H O O L

6.4.6 P a rrish - C h u rch [ _____ ] W M P A R C H R

6.4.7 N o th ir d p a r ty ta k e s p a r t o f th is , I t is ju s t d e a lt w ith W ith in th e fa m ily o r w ith c lose fr ie n d s [ _____ ] W M IN F M L Y

6.4.8 C o m m u n a l A u th o r i t ie s [ _____ ] W M N A U T C M

6.4.9 N G O (S p e c ify ): (® S P W M N G O [ _____ ] W M N G O O T H

6.4.10 O th e r (S p e c ify ): (® W M SP C O R 1 [ _____ ] W M O T H O R 1

6.4.11 O th e r (S p e c ify ): (® W M S P C O R 2 [ _____ ] W M O T H O R 2

6.4.12 O th e r (S p e c ify ): (® W M S P C O R 3 [ _____ ] W M O T H O R 3

6.5 6.5.1 6.5.2 6.5.3 6.5.4

21s there a at LOCALITY ? /Where is the closest ? /Are local people atLOCALITY familiar with the role/functions of the

?

01=Y es

0 0 = No

77=N K

/Do local people use the services provided bv ?

01=Y es

00= N o

77=N K

01=Y es (go to 6.5.3)00= N o

77=N K

(Name of the locality)If Don't KNOW, go to the next line

1 . DISTRICT DISTW HR DISTFNC DISTUSE

2. O th e r O TH R D N A O THRW HR OTHRFNC OTHRUSE

6.6 Field Worker: Write relevant observations/comments in the following box.

Write first the number of the question you refer to.


C O M M E N TSENTRYID

1

2

3

4

5



6.0.3 Interview concludes: Hour ____ • _____ INTENDH

YOUNG LIVES ROUND 4 SURVEY PERU JUNE TO DECEMBER 2013 ...

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