Chronic Disease Risk Factor (CDRF) Study
(Funded by the Wellcome Trust, U.K)

HOUSEHOLD QUESTIONNAIRE

Name of Respondent: ________________________________
Contact Details:
Name of Head of Household : __________________________
House Address: ________________________________ [House No./Street/locality]
________________________________
PIN Code: ________________________________
Phone No: 1) __________________ 2) ______________
Email ID: 1) __________________ 2) ______________
Alternative contact details
Name: ________________________________
House Address: ________________________________ [House No./Street/locality]
________________________________
PIN Code: ________________________________
Phone No: 1) _______________ 2)_________________

Interviewer Details (for each visit, up to 3):

Visit #1: Interviewer code (initials): Date of Interview (dd/mm/yyyy): / /

Visit #2: Interviewer code (initials): Date of Interview (dd/mm/yyyy): / /

Visit #3: Interviewer code (initials): Date of Interview (dd/mm/yyyy): / /

Supported by

SOUTH ASIA NETWORK FOR CHRONIC DISEASE, PUBLIC HEALTH FOUNDATION OF INDIA
&
LONDON SCHOOL OF HYGIENE & TROPICAL MEDICINE, U.K.

1. About your household S. No | 1.1 Names of persons who usually reside with family (for most days in last six months) (excl. servants /staff) | 1.2Age | 1.3Gender | 1.4 What is your relationship to head of household | 1.5 Completed consent form? | 1.6 If ‘No’, reasons?Stop here for refusers | 1.7 For how many years have you lived in this household? | 1.8 Can we re-contact you for a follow-up visit? | ** | Start with the oldest member | Years | Male=1, Female=2 | Use codes | 1=No, 2=Yes3=Not Eligible | | | 1=No, 2=Yes, 3= Not sure | | | | | | |