QUESTIONS -English QUESTIONS -Bahasa Indonesia PROMPT / OPTIONS -English PROMPT / OPTIONS -Bahasa Indonesia NOTES
## WATER ACCESS AND QUALITY
59 What is your household’s main source of drinking water? Sumber air bersih
* main utama PDAM PDAM
* additional tambahan purchased bottled water/ purified/ distilled water beli di toko atau pedagang air keliling
* purchased tanker truck/peddler
* relative importance piped water system -individual household access
* piped water system -access via other households (HHS)
* piped water system -access via single village / community sourcepoint
* dug/ shallow well - personal use / individual household access
* dug/ shallow well - shared access with other households (HHS)
dug/ shallow well -access via single village / community sourcepoint
* artesian shallow well - personal use / individual household access
* artesian shallow well - shared access with other households (HHS)
* artesian shallow well -access via single village / community sourcepoint
* artesian deep well - personal use / individual household access
* artesian deep well - shared access with other households (HHS) sumur umum
* artesian deep well -access via single village / community sourcepoint
* spring water, specify mata air, tentukan
* river, stream, lake, spring and/or other natural water sources sungai
* rainwater air hujan
* other (specify) lainnya (sebutkan)
60 How far is it to this source?
* under 100m
* 100m to 1 km
* over 1 km
61 How long does it take for each return trip to gather water from this source? (minutes/hours)
62 How do you get there, on average? Bagaimana Anda sampai di sana, rata-rata?
* on foot berjalan kaki
* on foot, with hand trolley berjalan kaki, dengan tangan troli
* bicycle, self-owned sepeda, milik sendiri
* bicycle, borrowed sepeda, dipinjam
* bicycle, rented / hired sepeda, menyewa
* motorbike, self-owned sepeda motor, milik sendiri
* motorbike, borrowed sepeda motor, dipinjam
* motorbike taxi ojek
* car, self-owned mobil, milik sendiri
* car, rented / hired mobil, menyewa
* van, self-owned van, milik sendiri
* van, rented / hired van, disewa
* bus, hired bus, disewa
* non-motor boats: catamaran perahu tanpa motor: jukung
* non-motor boats: small perahu tanpa motor: kecil
* non-motor boats: medium perahu tanpa motor: sedang
* non-motor boats: large perahu tanpa motor: besar
* outboard motor boat perahu motor tempel
* onboard motor boat kapal motor
* public transportation transportasi umum
* others (specify) lainnya (sebutkan)
63 How much does it cost to get there, if any?
* no cost
* (rupiah)
64 What is your daily consumption of water for drinking? Apa konsumsi sehari-hari Anda air untuk minum / mandi? (liters/pails/gallons/tanks)
65 How plentiful (quantity) is the availability of your water sources?
* abundant
* adequate
* scarce
* unknown / uncertain
66 How is the quality of your water sources?
* good
* bad
* unknown / uncertain
67 color
* opaque
* colored / tinted
* clear
68 taste
* has good taste memiliki selera yang baik
* has bad taste memiliki rasa yang buruk
* tasteless hambar
69 odor
* has odour memiliki bau
* odourless tanpa bau
70 Has the water been tested for chemicals/microbiological contents?
* yes (results) ya (hasil)
* no (note reason, if given) tidak ada (catatan alasan, jika diberikan)
* unknown / uncertain tidak diketahui / tidak pasti
71 Are you aware if your water is treated with any purification process before consuming it?
* no purification, drink directly tidak ada pemurnian, minum langsung
* sedimentation pengendapan
* filtration penyaringan
* distillation distilasi
* flocculation flokulasi
* chlorination klorinasi
* UV lights/ozon lampu UV / ozon
* others (specify) lainnya (sebutkan)
72 Do you sterilize / disinfect your water before consuming it?
* no desinfection, drink directly
* boiled
* others (specify)
73 What is your primary clean water source for bathing? Apa sumber air utama Anda bersih untuk minum / mandi?
* main utama PDAM PDAM (if multiple answers given, record order of priority)
* additional tambahan purchased tanker truck/peddler
* relative importance? piped water system -individual household access
* piped water system -access via other households (HHS)
* piped water system -access via single village / community sourcepoint
* dug/ shallow well - personal use / individual household access pribadi sumur gali
* dug/ shallow well - shared access with other households (HHS) tetangga 'sumur gali
* dug/ shallow well -access via single village / community sourcepoint tetangga 'sumur gali
* artesian shallow well - personal use / individual household access sumur bor
* artesian shallow well - shared access with other households (HHS) sumur bor
* artesian shallow well -access via single village / community sourcepoint sumur bor
* artesian deep well - personal use / individual household access sumur umum
* artesian deep well - shared access with other households (HHS) sumur umum
* artesian deep well -access via single village / community sourcepoint sumur umum
* spring water, specify mata air, tentukan
* river, stream, lake, spring and/or other natural water sources sungai, tentukan
* rainwater air hujan
* other (specify) lainnya (sebutkan)
74 How long does it take to get to your primary water source? Berapa lama waktu yang diperlukan untuk sampai ke sumber air utama Anda?
* (meters/kilometers)
* (minutes / hours)
75 How do you get there, on average? Bagaimana Anda sampai di sana, rata-rata?
* on foot berjalan kaki
* on foot, with hand trolley berjalan kaki, dengan tangan troli
* bicycle, self-owned sepeda, milik sendiri
* bicycle, borrowed sepeda, dipinjam
* bicycle, rented / hired sepeda, menyewa
* motorbike, self-owned sepeda motor, milik sendiri
* motorbike, borrowed sepeda motor, dipinjam
* motorbike taxi ojek
* car, self-owned mobil, milik sendiri
* car, rented / hired mobil, menyewa
* van, self-owned van, milik sendiri
* van, rented / hired van, disewa
* bus, hired bus, disewa
* non-motor boats: catamaran perahu tanpa motor: jukung
* non-motor boats: small perahu tanpa motor: kecil
* non-motor boats: medium perahu tanpa motor: sedang
* non-motor boats: large perahu tanpa motor: besar
* outboard motor boat perahu motor tempel
* onboard motor boat kapal motor
* public transportation transportasi umum
* others (specify) lainnya (sebutkan)
76 How much does it cost to get there, if any?
* no cost
* (rupiah)
77 For what other purposes do you use water?
* irrigation for agriculture
* irrigation for plantations
* water for livestock
78 How much water would you estimate that you consume on average each day? (liters/pails/gallons/tanks)
79 Have your ever experienced any water shortage?
* yes (duration in month/season) ya (durasi bulan / musim)
* yes (duration in days/weeks/months) ya (durasi dalam beberapa hari / minggu / bulan)
* no / have not experienced tidak / belum mengalami
* cannot recall tidak ingat
80 How do you find an alternate for water resources?
* never have needed alternative source pernah diperlukan sumber alternatif
* look for other water resources (distance / km) mencari sumber air lainnya (jarak / km)
* purchase water (cost /liter/pail/gallon/tank etc.) air pembelian (biaya / liter / pail / galon / tangki dll)
* use rainwater menggunakan air hujan
* others (specify) lainnya (sebutkan)
## RESIDENCE / DWELLING LIVING CONDITIONS
81 What is the main source of fuel for household cooking?
* wood fuel kayu
* charcoal arang
* coal batubara
* kerosene gas (minyak tanah / kompor minyak tanah)
* LPG (or bottled gas) -non-subsidy LPG (atau gas botol) -Non-subsidi
* LPG (or bottled gas) -subsidized green gas tank LPG (atau gas botol) -subsidized tangki bensin hijau
* LPG (or bottled gas) -subsidized blue gas tank LPG (atau gas botol) -subsidized tangki bensin biru
* electricity listrik
* other (specify) lainnya (sebutkan)
82 Are cooking activities conducted indoor?
* yes ya
* no tidak
83 condition of air circulation (filled in based on observation)
* bad buruk
* moderate moderat
* good baik
84 Does the residence / structure / house have adequate ventilation? Apakah rumah bapak/ibu memiliki ventilasi udara yang cukup memadai?
* yes ya
* no tidak
* do not know tidak tahu
85 Type of existing ventilation? Jika ya, bagaimana kondisi ventilasi rumah yang bapak/ibu tempatin sekarang? (filled in based on observation)
* window jendela
* the open roof atap terbuka
* spaces between plaited bamboo/rattan wall celah-celah dinding kayu (bambu atau rotan)
* other (specify) lainnya (sebutkan): .........
86 Condition of lighting/illumination? “pencahayaan rumah” (filled in based on observation)
* dark gelap
* moderate moderat
* bright cerah
*
87 Does adequate sunlight get into the house? Apakah rumah bapak/ibu mendapatkan sinar matahari yang cukup?
* yes ya
* no tidak
* do not know tidak tahu
88 What kind of lighting is used? (may give more than one answer) Jenis penerangan apa yang digunakan? (may give more than one answer)
* electricity listrik
* oil/petromax
* oil/kerosene/petromax light lampu petromax to combine with secondary data or socio-economic survey
* lampu minyak tanah
* solar cell lamps
* candle / paraffin lilin / parafin
* others (specify) lainnya (sebutkan)
89 Is there any difficulty in getting the energy source? Apakah ada kesulitan dalam mendapatkan sumber energi tersebut? (if not, go to qX) (jika tidak, lanjutkan ke pertanyaan X)
* yes ya
* do not tidak
* do not know tidak tahu
90 If yes, type of difficulties faced in what form? Jika ya, jenis kesulitan yang dihadapi dalam bentuk apa?
91 How the father / mother face difficulties? Bagaimana bapak/ibu menghadapi kesulitan tersebut?
92 Is there electricity in the house/ building?
* if yes, proceed to qX,
* if not proceed to qY
94 What is the main source of electricity to the dwelling? sumber energi
* main utama electric company (name?)
* additional tambahan government electricity (PLN) -direct connection listrik pemerintah (PLN)
* government electricity (PLN) -connected from neighbours listrik pemerintah (PLN), yang dihubungkan dari tetangga
* personal generator generator pribadi
* generator, connected from neighbours
* gas generator gas generator
* kerosene generator minyak tanah
* solar Tenaga Surya
* battery
* obor
* lampu minyak tanah
* others (specify) lainnya (sebutkan)
## RESIDENCE / DWELLING STRUCTURAL CONDITIONS
95 Does your household own the dwelling in which you are currently living? Status kepemilikan tempat tinggal / struktur / rumah yang sekarang ditempati?
* yes -personally owned dimiliki secara pribadi
* no -rented/contracted menyewa / kontrak
* no -boarding with others asrama dengan orang lain
* no -living in others’ yard tinggal di halaman orang lain
96 Permanency of the residence/ structure/ house currently occupied? Pekerjaan tetap tempat tinggal / struktur / rumah yang sekarang ditempati? // Bagaimana kondisi rumah bapak/ibu?
* permanent permanen
* semi permanent semi permanen
* shack/temporary shelter sementara
97 What is the size of the house? (area in m2)
98 How many rooms does the house have?
99 From what materials was the residence / household / structure built? Dari bahan apa yang kediaman / rumah tangga / struktur dibangun?
* Apa kondisi fisik dari rumah bapak/ibu? wooden simple house
* wooden stilt house (rumah panggung)
* brick
* concrete
* other (specify) lainnya (sebutkan)
100 What is the wall material for your house?
101 Roof typed of occupied house? Bagaimana kondisi atap rumah bapak/ibu? (filled in based on observation)
* thatched roof atap rumbia/alang-alang
* shingle roof atap sirap - ulin
* tile genteng
* pottery tembikar
* zinc seng
* galvanized corrugated roof
* asbestos asbes
* asbestos corrugated roof
* wood/plywood kayu/triplek
* other (specify) lainnya (sebutkan)
102 Floor typed of occupied house (filled in based on observation) Bagaimana kondisi lantai rumah bapak/ibu?
* hard soil tanah keras (lantai tanah)
* plywood triplek
* wood kayu
* cemented floor semen
* tile/ceramic tile (lantai ubin) ubin/keramik (lantai ubin)
* others (specify) lainnya (sebutkan)
103 What are the characteristics of traditional housing?
104 What materials are commonly used in creating shelters? Bahan apa yang lazim digunakan dalam membangun bivak?
105 Are any building materials hard to come by? Apakah ada bahan bangunan yang sulit diperoleh?
106 What is the average value for different types of houses in this area?
107 Do you estimate there is an active market for renting houses in this area?
108 Can you please help us try to estimate the rent different house types in this area?
109 Can you estimate the rent for a single room?
## SANITATION AND PERSONAL HYGENE
110 What facilities does your family use for bathing?
* season: bucket, in own home
* dry bucket, in neighbour's home
* rainy personal bath, indoors
* personal bath, outdoors
* neighbours’ bath, indoors
* neighbours’ bath, outdoors
* public MCK (bathing, washing & latrine)
* river
* mangrove
* ocean
* other (specify)

| 111 | What kind of toilet facility does the household mainly use? | | | | | | * | season: | | no toilet | | | | * | dry | | bucket, in own home | | | | * | rainy | | bucket, in neighbour's home | | | | * | | | personal water-flush latrine, indoors | | | | * | | | personal water-flush latrine, outdoors | | | | * | | | personal pit latrine, outdoors | | | | * | | | neighbours’ water-flush latrine, indoors | | | | * | | | neighbours’ water-flush latrine, outdoors | | | | * | | | neighbours’ pit latrine, outdoors | | | | * | | | public / community closed pit latrine (shared) | | | | * | | | public / community open pit latrine (shared) | | | | * | | | public / community MCK (bathing, washing & latrine) | | | | * | | | open yard | | | | * | | | in the forest | | | | * | | | in a river | | | | * | | | in a mangrove | | | | * | | | in the ocean | | | | * | | | others (specify) | | |

| 112 | Disposal of bathing/cleaning wastewater | | | | | | * | | | in the forest | | | | * | | | seep on ground | | | | * | | | to gutter near house | | | | * | | | to pond near house | | | | * | | | in the river (specify) | | | | * | | | mangrove | | | | * | | | ocean | | | | * | | | storage cesspool (cubluk) | | | | * | | | septic tank | | | | * | | | other (specify) | | | | 113 | How do you mainly dispose of household solid waste/ garbage (e.g. food/kitchen/domestic waste) | | | | | | * | | | landfill near house, burnt when pile up | | | | * | | | landfill near house, pick up by municipal waste service | | | | * | | | collected by village/ LGU | | | | * | | | compost | | | | * | | | burn | | | | * | | | bury in the ground | | | | * | | | throw in the river | | | | * | | | throw to open yard | | | | * | | | other (specify) | | | | ## | ENVIRONMENTAL HEALTH AND SECURITY | | | | | | 114 | What is your perception of the quality/health of the environment around your house? | | | | | | * | | | good | baik | | | * | | | moderate | moderat | | | * | | | bad / poor | buruk / miskin | | | 115 | How many traffic accidents, spills, releases or injuries have there been in the last 12 months? | | | | | | 116 | What potentially hazardous materials is the community currently exposed to in the area? | | | | |