1
Attachment 3
SUSENAS
VSEN99.GY
1
REPUBLIC OF INDONESIA
CENTRAL BUREAU OF STATISTICS
HOUSEHOLD IODIZED SALT SURVEY
(INTEGRATED WITH 1999 SUSENAS)
Confidential
I. LOCATION IDENTIFICATION
01
02
03
04
05
06
07
08
09
10
01
02
03
Province
District/Municipality *)
Sub-district
Village/Village Unit*)
Area
Enumeration area number
Segments group number
Segment number
Sample code number
Village classification
Urban
1
Least developed village
Developed village
II. SUMMARY
Number of households:
Number of households based on iodized salt level:
a. Enough iodine:
……..households
b. Not enough iodine:
……..households
c. Does not contain iodine:
……..households
Number of households using salt at home
(Total Q.2.a to Q.2.c)
2
1
2
For cooking
Fill in at
CBS
Other salt
……..households
III. ENUMERATION PARTICULARS
Name and NIP of enumerator
Enumerator’s occupation:
Provincial staff 1
District staff 2
03
Date of enumeration
04
Signature of enumerator
*) Cross out inapplicable category
01
02
Rural
Sub-district staff
Partner
3
4
2
3
Serial
number
Name of
respondent
(1)
(2)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Codes for column (3):
The head of household
Wife/husband
Children
Son/daughter in-law
Grandchildren
IV. HOUSEHOLD AND IODIZED SALT CONSUMPTION LISTING
(Result of interview, observation and checking)
Do you use
Do you
Relation
If
If
If column
iodized salt at column
know the
to the
Column
(4)=2, do
home?
use of
head of
(7)=2,
you use salt (4)=1,
household Iodized
where
at home?
Yes
1↓ reason
Salt?
(code)
not using
Yes
1↓ did you
Column (9)
get
the
iodized
Yes
1↓
No
2
Column (9)
informa- Does not 3
salt
2
Column (6) No
tion for
(code)
(finished)
No
2
use salt↓
the first
(finished)
time?
(code)
(3)
(4)
(5)
(6)
(7)
(8)
1
2
3
4
5
Parent/In-law
Other relative
Servant
Others
6
7
8
9
Where do
you buy
salt?
Market 1
Stall
2
Remote 3
Vendor
Other
4
(9)
Codes for column (6):
Codes for column (8):
Neighbor/family 1
PKK woman
2
Radio, TV,
3
Newspaper
Nearest vendor/market/ 1
Shop does not sell iodized
salt
Doesn’t like the taste 2
Expensive
3
Other
4
Health advisor 4
Education
5
Other
6
4
5
Salt
purchased
from
(code)
IV. HOUSEHOLD AND IODIZED SALT CONSUMPTION LISTING
(Result of interview, observation and checking)
Salt used for cooking
Type of salt:
Table/fine 1
salt
Coarse 2
Cube
3
(10)
(11)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
Codes for column (10):
Local
1
Non local
2
Don’t know
3
Brand
(12)
Salt
storage
container
(code)
How is the
salt stored
Covered
1
Uncovered 2
Salt
location
(code)
Level of
iodized salt
Enough 1
Not
2
Enough
None
3
(13)
(14)
(15)
(16)
Codes for column (13):
Ceramic
1
Plastic
2
Glass
3
Metal
4
Other
5
Codes for column (15):
Above the stove
Inside a cabinet
On top of the table
Other
Other level of
iodized salt
Enough
1
Not enough 2
None
3
Not using 4
other salt
(17)
1
2
3
4
6
7
SUSENAS
VSEN99.GY
2
REPUBLIC OF INDONESIA
CENTRAL BUREAU OF STATISTICS
HOUSEHOLD IODIZED SALT SURVEY
(INTEGRATED WITH 1999 SUSENAS)
Confidential
06
07
I. LOCATION IDENTIFICATION
Province
District/Municipality *)
Sub-district
Village/Village Unit*)
Area
1. Urban
2. Rural
Enumerator area number
Segments Group number
01
08
Segment number
02
09
10
Sample code number
Village classification
01
02
03
04
05
1. Least development village
2. Development village
01
02
03
fill in
by editor
03
04
II. SUMMARY
Number of households
……household
a. Number of women aged 15-49 years
……persons
……persons
a.1. Number of pregnant women
……persons
a.2. Number of non-pregnant women
Number of “Balita” (household members aged 0 – 5 ……persons
years
III. ENUMRATINON PARTICULARS
Name and employment identity number of
Name & employment identity number
enumerator
of supervisor
Enumerator’s occupation:
Supervisor’s occupation:
Midwife in the village
1
Provincial staff
1
‘Posyandu’ cadre
2
District staff
2
‘PKK’ cadre
3
Sub-district staff
3
Others (staff, sub-district)
4
Date of enumeration
Signature of enumerator
*) cross out inapplicable category
8
9
IV. ‘BALITA’ AND WOMEN AGED 15 – 49 YEARS OLD CHARACTERISTICS
Sample
house hold
serial
number
(Taken
from Q.10,
Block 1,
VSEN99.K)
1
Women aged 15 – 49 ears old
Taken from Column 1,2 and 5, Block
IV.A, VSEN99.K
House hold
member
serial
number
Name of
house hold
member
2
3
Age
(year)
4
Marital
status
(Taken from
column 6,
Block IV.A,
VSEN99.K)
If Col.5 #1,
pregnancy
status
Pregnant
1
Not
2
pregnant
5
6
Size of
‘LILA’
(cm)
7
Sample
house hold
serial
number
(Taken from
Q.10, Block
1,
VSEN99.K)
8
“Balita” (household members aged 0 – 5 months)
Taken from Column 1,2 and 4, Block
IV.A, VSEN99.K
Serial
number of
house hold
member
9
Name of
household
members
10
Gender:
M
1
F
2
11
Age
(month)
{Taken
from Q.7.a,
Block V,
VSEN99.K
}
12
Weight
(Kg)
13
10