QUESTIONS -English	QUESTIONS -Bahasa Indonesia	PROMPT / OPTIONS -Englsih	PROMPT / OPTIONS -Bahasa Indonesia	NOTES

HOUSEHOLD HEALTH & TREATMENT BEHAVIOR

302 What is your perception of the health of your household?

303 Has any member of your household been sick in the last 30 days?

304 Which of the following sickness / illness / condition have members of the households suffered in the last year? Selama 12 bulan, apakah ada anggota keluarga bapak/ibu yang mengalami penyakit di bawah ini?

305 Did sick member seek treatment?

306 If yes, from whom was treatment sought?

307 How much did you / your family pay to get the health services?

308 How far was it to the treatment/health facility? Berapa jauh jarak dari rumah bapak/ibu ke tempat pengobatan?

309 How did you / your family member get there?

310 How much does it cost to get there, if any?

311 If you did not seek treatment, what was your reason?

312 If did not seek treatment, what did you do in order to recover?

313 If a member of your household were to become ill in the future, where would you most likely take them for diagnosis and treatment? Jika bapak/ibu dan atau anggota keluarganya sakit, dimana biasanya mereka dibawa berobat?

314 If a member of your household were to become ill in the future, how would you pay for it? Bagaimana bapak/ibu membayar pengobatan penyakit?

315 What health facilities exist in the area?

316 How far away is the nearest treatment/health facility? Berapa jauh jarak dari rumah bapak/ibu ke tempat pengobatan? kilometers:

317 How would you get to a treatment facility?

318 How much do you estimate transportation would cost to each facility? Berapa biaya yang dikeluarkan untuk menuju ke tempat pengobatan? rupiah:

319 How many qualified health professionals are there for each facility?

320 How many traditional healers are there in the area?

321 What pharmacies exist in the area?

322 What personal, social, economic, institutional and environmental factors do you feel affect public health in this area?

323 What traditional knowledge, attitudes and beliefs exist in the area?

324 What are the prevalence rates for non-communicable diseases (hypertension, diabetes cardiovascular disorders, cancer) in the area?

USE OF TRADITIONAL MEDICINE

325 How important is the use of traditional medicine to your or members of your household?

326 Is there a traditional / natural healer in this village?

327 Have you ever used traditional medicine?

328 Do you know many natural / traditional remedies?

329 Where did you get traditional medicines? Dimana bapak/ibu mendapatkan tanaman obat tradisional tersebut?

330 What kind of plants / animals / ingredients are commonly used to make medicine?

331 Is there a particular person in the community who collects ingredients for traditional medicine?

332 Do you, or members of your household, collect any ingredients for traditional medicine locally (herbs, etc)?

333 What natural resources / species are targeted?

334 What are they used for?

335 Are pythons or bats or any other species caught for medicinal purposes?

336 Did you find it difficult to find / gather / obtain the ingredients for traditional medicines? If so, why? Apakah bapak/ibu memiliki kesulitan mendapatkan tanaman obat tradisional tersebut? Jika ya, kenapa?

337 Have you noticed any trends in the availability of natural medicines?

338 Are there alternative locations where medicinal herbs could be collected and, if so, where are these located?

339 Are there any restrictions on the collection of plants for medicinal purposes (e.g. permits / licenses required)?

340 Is there any collection of natural medicines (herbs, etc) in the project area?

341 What are they used for?

342 Are there alternative locations where medicinal herbs could be collected and, if so, where are these located?

343 Are there any restrictions on the collection of plants for medicinal purposes (e.g. permits / licenses required)?

343 Are pythons or bats or any other species caught for medicinal purposes?

TARGETED QUESTIONS FOR MEDICAL PRACITIONERS / HEALTH AGENCIES

344 What are the most common diseases amongst local communities living within or immediately around the project area?

345 Are any of these waterborne or could they be attributed to environmental factors (e.g. transmission by birds/mammals, standing water, vegetation clearance)?

346 What vector related diseases (malaria, schistosomiasis, dengue, onchocerciasis etc) are present in the area?

347 What is the prevalence of soil and water borne disease (giardiasis, worms, water access & quality, sanitation) in the area?

348 What is the prevalence and incidence of respiratory issues (acute respiratory infections [bacterial & viral], pneumonia, tuberculosis) from housing conditions, overcrowding and house inflation?

349 What is the prevalence of zootonic issues (Brucellosis, rabies, bovine TB, bird flu etc.) in the area?

350 What is the prevalence of sexually transmitted disease in the area?

351 Are there any food and nutrition issues [stunting, wasting, micronutrient diseases, gastroenteritis (bacterial and viral)] that are especially prevalent in the area?

352 What personal, social, economic, institutional and environmental factors determine the status of population health in the area?

MORTALITY AND MORBIDITY

353 Was any member of the family born in the past 12 months? yes (go to qX)

354 How is the baby's' health assessed at birth (according to which diagnostic criteria)?

355 Did any member of the household die in the past 12 months? Apakah bapak/ibu memiliki anggota keluarga yang meninggal selama 12 bulan terakhir? yes

356 Please indicate the cause of death.

DISABILITY

357 Does any member of the household have any disabilities?

358 Please indicate the type of disability

359 Does the disabled person receive any forms of support/ or assistance?

HEALTH BEHAVIOUR

360 Do you smoke?

361 If yes, do you smoke inside the house and near children?

362 Do you consume alcohol?

363 How often do you drink alcohol?

364 Are you influenced after drinking alcohol?

NUTRITION NUTRISI

365 Do you eat regular meals? Berapa kali bapak/ibu dan anggota keluarga makan setiap hari?

366 Are there any types of food that you prefer over others?

367 Are there any types of food that are difficult to maintain?

368 Are there any types of food that are considered "prestigious"?

369 Are there any types of food that you eat mostly / only for ceremonial occasions?

370 Have you experienced any food shortages during the past 12 months? Apakah bapak/ibu pernah mengalami kekurangan makanan selama 12 bulan terakhir?

371 If so, in what month? Jika pernah, di bulan apa?

372 Do you find alternates for the food?

SANITATION AND PERSONAL HYGENE

373 Do you have access to hygienic facilities for bathing, washing and waste water? Apakah bapak/ibu memiliki fasilitas higienis untuk mandi, cuci dan buang air?

374 If you do not have access to hygienic facilities, where to you go to attend to personal hygiene? Jika tidak punya, dimana bapak/ibu biasanya melakukan kegiatan higienis?

375 Do you wash hands before eating or after defecating?

376 Do you take regular bath?