TRIBHUVAN UNIVERSITY

SAPTAGANDAKI MULTIPLE CAMPUS

FACULTY OF EDUCATION
DEPARTMENT OF HEALTH EDUCATION
COMMUNITY HEALTH SURVEY
Date of Interview: ..................
Part I
Interview:
1.
Demography
i) District .
iii) Ward No. ..
v) Householder Name .
vii) Language .
ix) Religion .
2.
Family Status
Sex
Name of
S.N.
Age
Occupation
Members
M F
1.
2.
3.
4.
5.
6.
7.

ii) MPL/VDC .
iv) Household No
vi) Type of family
viii) Caste .
x) Sex .
Education
ill lit Qua

Marital
M UM

Alco

Code L = Labor
Fe = Foreign Employer
Qua = Qualified
S = Service
St = Student
Ill= Illiterate
Um = Unmarried
List = Literate
M = Married
3.
Economic Status
3.1
Main source of income
A
L
FE
S
St
B
3.2
Mainly spend on
Food
Medicine
Edu
Entertainment
3.3
Do you have your own land
Yes
No
3.4
If yes how much Bigha..
Katha Dhur.
No..
3.5
Vehicle/transport
Cycle
Motorcycle
Gada
No
3.6
Facilities in Elect home
Radio
TV
Phone
Comp.
Other..
3.7
Domestic animal
Buff.
Cow
Ox
Goat
Hen
Other
3.8
Is your domestic production enough?
Yes
No

Smoke

3.9

4.
4.1
4.2
4.3
4.4

4.5
4.6

5.
5.1.1
5.1.2
5.1.3

5.2
5.2.1
5.3.1

5.3.2
5.3.3
5.3.4
5.3.5

What is the main crops do your produce?

Rice
Maize
Wheat
Crops

Mustard

Cash

Veg.

Social Cultural Status:

Who is responsible for sex determination in your opinion?
a) God
b) Father
c) Mother
d) Both
e) Dont know
Do you isolate your women member during menses and pregnancy?
a) Yes
b) No
c) Dont know
Do you believe in god and evil sprit?
a) Yes
b) No
Is your family spending your leisure period?
a) Entertainment
b) Sleeping c) Talking and gathering
d) Doing productive work
Is your family member drinking alcohol in socio-cultural functions?
a) Yea
b) No
How do you get health related information?
a) Radio
b) TV
c) Newspaper
d) Neighbors
Environmental Health
What is your main source of drinking water?
a) Well
b) Tube well
c) Tap
Do you caver the drinking water pot?
a) Yes
b) No
How do you drink water?
a) Boiling
b) Filtering
c) Nothing
Housing
What thing to you use to cook food?
a) Wood
b) Gobar gas
c) Cylinder gas
Where do you dispose your wastages materials?
a) Manure pit b) Dump in on the open field
d) Certain area
Do you have your own latrine?
a) Yes
b) No
If.where do you go for fasces?
a) Farm
b) Jungle
c) Open area
Do you have drainage facility?
a) Yes
b) No
If not, where do you dispose the sewage?
a) In the manure pit
b) Seepage pit
c) In the kitchen garden
d) Other (.) specify.

d) Other

d) Stove

e) Other

c) Throwing haphazardly

d) Others

6.
6.1
6.2
6.3
6.4
6.5

6.6

7.
7.1
7.2
7.3
7.4

7.5
7.6
7.7

7.8
7.9
7.10

7.11
7.12

Personal Hygiene.
When do you brush your teeth
a)Early in the morning
b) After meal
Of Yes, what do your use for brushing?
a) Ready made paste b) Coal
c) Neem
d) Others
How many days interval do you both?
a) Daily
b) Weekly
c) Monthly
d) Twice a week
Do you wash your hands before meal and after toilet?
a) Yes
b) No
What do you use for washing hands?
a) Ash with water
b) Only water
c) Soap with water
d) Mud with water
How often do you cut you nails?
a) Weekly
b) Monthly
MCH (Maternal and child health)
When did you get marry?
a) Before 20s
b) After 20s
In which age did you get first pregnancy?
.
How many children do you have?
a) One
b) Two
c) 3 and more than 3
d) Not yet
Have you had antenatal check up at last pregnancy?
a) Yes
b) No
If, No why?
a) No-need
b) No time
c) Clinic is to far d) Lack of knowledge
If yes, how many time?
a) Less than 4 b) 4 times
c) more than &
When did you start antenatal visit after pregnancy?
a) 3 months
b) after 3 month
c) before 3 month
Where do you to check up?
a) Health post/SHP
b) Sudeni
c) Hospital
d) Private Clinic
Have you take iron table during pregnancy?
a) Yes
b) No
Have you take TT vaccine during pregnancy?
a) Yes
b) No
Where do you for delivery?
a) Sundeni
b) Home
c) Health post & SHP
d) Hospital
If home or Sudeni do you use delivery kit?
a) Yes
b) No
If Not what is used to cut the cord?
a) Knife
b) Blade
c) Scissors

7.13

7.14
7.15
7.16
7.17
7.18
7.19
7.20
7.21
7.22

8)
8.1

8.2
8.3

8.4
8.5
8.6
8.7
8.8

Where do you keep women for delivery?

a) Cow shed
b) Common room
c) Well prepared room
d) Other
Have you given green vegetable for delivery women?
a) Yes
b) No
After delivery have many times do you take rest?
a) .days
b) Less than 3 month
c) More than 3 moths
Do you have any abortions?
a) Yes
b) No
If yes have many times?
a) 1
b) 2
c) More than three
Do you have any complications during?
a) Yes
b) No
Do you feed colostrums (First day milk) to your child?
a) Yes
b) No
If not why?
a) Lack of knowledge
b) Causes disease
c) Hard digest
Have you kept baby in morning sunlight?
a) Yes
b) No
If yes how to prepare it?
a) Full knowledge
b) No knowledge
c) Partial knowledge
Family Paining:
From where do you get the information about family planning?
a) Radio
b) T.V.
c) Health Post
d) Friends
e) Self
f) Others
Do you use contraceptive devices?
a) Yes
b) No
If not why?
a) Lack of knowledge
b) Lack of tactility
d) Due to its side effect
d) Due to religious be lick
If yes which types of devices is used?
a) Permanent
b) Temporary
If Permanent Method is used who?
a) Husband
b) wife
If temporary which?
a) Depo
b) Condom c) Natural Method
d) Others
In your opinion, what should be the birth spacing between two children?
a) 2yrs
b) 3yrs
c) 4 yrs
d) 5yrs
e) Above 5yrs
Do you have any problem after using contraceptive devices?
a) Yes
b) No

9.
9.1
9.2
9.3
9.4
9.5

Immunization
Do you have information about immunization?
a) Yes
b) No
What types of effect do we get in babies from the immunization?
a) Safe from disease
b) Healthy
c) other
Have you immunized children according to immunization schedule?
a) Yes
b) No
If not why?
a) Lack of facility
b) Lack of knowledge
In how many years should be complete vaccine to the baby?
a) 1yrs
b) 2yrs
c) 3rsy
d) 5yrs

Food and Nutritions:

What is your daily meal?
a) Dal, Bhat and tarkaree
c) Dhido and tarkaree
c) ..
10.2 Do you take fruits?
a) Yes
b) No
10.3 What do you do before cooking the vegetable firstly?
a) Washing and cutting
b) Cutting and washing
10.4 At what age of your child do you start the supplemental food?
a) Before 6 month
b) After 6 month
10.5 What thing of supplementary food do you feed your child?
a) Jaulo
b) Sarbottam pithokio lito
c) Cow, buffalos milk
d) Dal bhat
10.6 Do you have kitchen garden?
a) Yes
b) No
10.7 Do you have knowledge of malnutrition?
a) Yes
b) No
10.8 What is the causes of malnutrition?
a) Lack of nutrition
b) Over food
c) Evil sprits
10.9 How many time do you take meal in a day?
a) 2 times
b) 3 times
c) 4 times
10.10 Do you take green leafy vegetables in your meal daily?
a) Yes
b) No
c) Hospital
10.
10.1

11.
11.1

11.2
11.3
11.4

Disease prevention and control

What is the common disease often appearing in your family?
a) Pneumonia
b) Common cold
d) diarrhea
d) Chicken pox
e) Measles 4 .. (Specify)
Do you use jeevanjal during diarrhea?
a) Yes
b) No
How do you prepare Jeevanjal?
Do you know about night blindness?
a) Yes
b) No

11.5

If yes, what are the causes?

a) Lack of sanitation
b) Evil sprit
c) Lack of Vita A
d) Others .
11.6 If any person sick in your family at present?
a) Yes
b) No
11.7 If yes, by which disease hashers suffering?
.
11.8 How do you control the disease?
.
11.9 Is there any health institute in your community?
a) Yes
b) No
11.10 If, yes, which types of institute are presently?
a) Sub-health post
b) Health post
c) Hospital
11.11 Did any member of your family died during last one year?
a) Yes
b) No
11.12 If yes which sex?
a) Male
b) Female
11.13 What is cause of death?
a) Accident
b) disease
c) war
d) .Other
12.
12.1

12.2
12.3
12.4
13.
13.1
13.2
13.3
14.
14.1
14.2
14.3
14.4

Alcohol and Smoking

How did you start smoking alcohol?
a) Cultural
b) Father
c) Friends
d) Others
Why do you smoke alcohol?
a) for relax
b) To reduce tension
c) Nothing
Did you use to smoke alcohol at the pregnancy period?
a) Yes
b) No
How many rupees do you spend in months? In . Average?
Community needs problem
What are the major health problem of your community?
.
What are the important?
.
What kind of actuates do you like for fun enjoyment?
Observation:
Types of house
a) Kachha
Type of roof.
a) Concrete
Types of ventilation
a) poor
Provision of Toilet.
a) Pit

b) Pakka

c) Semi Pakkr

b) file

c) strow

b) moderate

c) proper

b) Water seal

c) Other

d) tin

14.5

14.6
14.7
14.8

Waste disposal system

a) In a container
c) Haphazard
Type so Kitchen?
a) Separate
Overall sanitation
a) Satisfactory
Cow shed present
a) Yes

b) Certain area
d) Manure pit
b) Attached
b) Unsatisfactory
b) No

Part-II
Preliminary information:
Name of the school:
Address:
Types (tick)
a) Government
b) Nongovernmental
1.4
Student enrollment
S.N.
Educational Year 064-065
Educational Year 036-064
1.
Boys
Girls
Total
Girls
Boys
Total
1.
1.1
1.2
1.3

1.5
Health school environment
S.N.
Location
Peaceful
A
Site
Near the village
B
Structure
Kachha
C
Furniture
Sufficient
D
Classroom
Sufficient wide
E
Blackboard
Good
F
Light and ventilation
Good
G
Door and windows
Good
H
Play ground
Sufficient
I
Drinking water supply
Good
J
Toilet
Yes
K
Waste disposal
In container
M Management of Tiffin
Yes
N
Library kaclity
Yes
O
Safety compound
Satisfactory
P
Student uniform
Yes
16.

Extra Curricular activities

I)
Indoor games
a) Regular
II)
PT/Drill
a) Regular
III)
Junior Red cross
a) Yes
IV)
scoot activities

Noisy
In the village
Pakka
Non-sufficient
Non-sufficient
Medium
Medium
Medium
Non-sufficient
Medium
No
Haphazard
No
No
Non-satisfactory
No

b) Irregular

c) No

b) Irregular

c) No

b) No

Middle
Far from the village
Stone/mud/cement
Poor
Poor
Poor
Poor
Poor
Poor
Poor