mFORM 1

DATA COLLECTION
QUESTIONNAIRE

COMMUNITY HEALTH NURSING (CHN)

STUDENTS OF AKADEMI KEPERAWATAN IBNU SINA KOTA SABANG
AND HEDMARK UNIVERSITY OF APPLIED SCIENCES NORWAY
2018

1. Respondent number :

2. Data collector : …………………………… Must be filled

3. Date of data collecting :
4. Village : Batee Shok 1 2
5. Sub-village : 1. Ateuh
2. Alue Jaba
3. Alue Jaya
4. Pria Laot
5. Sirui
6. District : Sukakarya 0 2
7. City : Sabang 0 1

I. FAMILY DATA
A. Identity of the head of the family
01. Initial: ……………………….
02. Age: ……. years 04. Occupation
03. Education A. [ ] Goverment employee/military/police
A. [ ] None B. [ ] Farmer/gardener
B. [ ] Elementary school C. [ ] Self-employed
C. [ ] Lower secondary school D. [ ] (unskilled) Labour
D. [ ] Upper secondary school E. [ ] Fisherman
E. [ ] Diploma/higher education F. [ ] Others (mention: ………….)

B. Dataof family members and medical history

No
Sex Age Education Occupation Diseases sufferred in the last Particular
(year/month) three months
1

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II.DATA OF ENVIRONMENTAL SANITY

1. Sunlight can get directly into the 5. Latrines ownership / toilets type:
house(Observe!) A. [ ] Goose neck + septic tank
A. [ ] Yes B. [ ] Communal + septic tank
B. [ ] No C. [ ] Cemplung ( a squat hole with a feces
storage right under it)+ septic tank
2. Ventilation (Observe!): D. [ ] Plesengan ( a squat hole connected to a
A. [ ] No ventilation feces storage by a sloping channel)+ septic
B. [ ] Not adequate tank
C. [ ] Adequate E. [ ] Not adequate
A. [ ] Open defecation
3. Water sources:
A. [ ] Protected dug well 6. Distance between the toilet/lantrine and the water
B. [ ] Hand-pump dug well resources:
C. [ ] Water wagon/water terminal A. [ ] <10 meters
D. [ ] Hand-pump artesian well B. [ ] ≥ 10 meters
E. [ ] Protected springs
F. [ ] Saved rainwater 7. What is done to household garbage?
G. [ ] Local Water Supply Company A. [ ] Burned
B. [ ] Collected and transported by dustman
4. Drinking water source: C. [ ] Carelessly dumped
A. [ ] Protected dug well D. [ ] Dumped into river/pond/sea
B. [ ] Hand-pump dug well E. [ ] Process into compost
C. [ ] Water wagon/water terminal
D. [ ] Hand-pump artesian well
E. [ ] Protected springs
F. [ ] Saved rainwater
G. [ ] Local Water Supply Company
H. [ ] Refill drinking water depot

III. HEALTH STATUS AND SERVICES

1. Health services which often visited: C. [ ] 3 – 6 months ago

A. [ ] Posyandu D. [ ] < 1 year ago
Center(s) for pre- and postnatal heatlh E. [ ] > 1 year ago
care and information for women and for
childre under five years 3. In your opinion, what is the current health status of the
B. [ ] Pustu whole family?
Community Health Sub-center A. [ ] Very good
C. [ ] Puskesmas B. [ ] Good
Community Health Center C. [ ] Deficient
D. [ ] Hospital D. [ ] Others (mention: ..........................................)
E. [ ] Private clinic
F. [ ] Others (mention:…..……..……..)

2. When was the last time you/other family

member(s) visit health facility?
A. [ ] < 1 month ago
B. [ ] 1 – 3 month(s) ago

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IV. HEALTH INFORMATION
Do the family member(s) get any health information in the last three months from the following sources?
No Source of information Yes No
1 Health personells
2 Caders
3 Magazines/newspaper
4 Radio/TV

Currently in your family, is/are there any:

1. [ ]Baby and children under five years (Proceed to Form 2)

2. [ ] Pregnant woman (Proceed to Form 3)
3. [ ] Postpartum mother (Proceed to Form 4)
4. [ ] Dental Health(Proceed to Form 5)
5. [ ] Smoking behaviour (Proceed to Form 6)

FORM 2

BABY AND CHILDR UNDER FIVE YEARS

(One Form for one child)

Child 1
1. Age 5. Vaccines reiceiced:
0 – 12month(s) HEPATITIS 0 [ ] Yes [ ] No
13 – 36months BCG [ ] Yes [ ] No
37 – 60months DPT 1/HB1 [ ] Yes [ ] No
DPT 2/HB2 [ ] Yes [ ] No
Weight : ……. kg DPT 3/HB3 [ ] Yes [ ] No
POLIO 1 [ ] Yes [ ] No
2. Does the child have Growth Chart/ Mother and POLIO 2 [ ] Yes [ ] No
Child Health Care book: POLIO 3 [ ] Yes [ ] No
A. [ ] Yes POLIO 4 [ ] Yes [ ] No
B. [ ] No Rubeola [ ] Yes [ ] No

3. Does the child get Vit. A in the last 6 months: 6. Was the child given initial colostrum/first milk?
A. [ ] Yes A. [ ] Yes
B. [ ] No B. [ ] No

4. Has the child weighed in the last 3 months? 7. When was the first time the child given weaning
A. [ ] Yes food:
B. [ ] No A. [ ] Since birth
B. [ ] < 4 months
C. [ ] 4 or 5 months old
D. [ ] Over 6 months old
E. [ ]Stil given breastmilk

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 Child 2
1. Age 5. Vaccines reiceiced:
0 – 12 month(s) HEPATITIS 0 [ ] Yes [ ] No
13 – 36 months BCG [ ] Yes [ ] No
37 – 60 months DPT 1/HB1 [ ] Yes[ ] No
DPT 2/HB2 [ ] Yes[ ] No
Weight : ……. kg DPT 3/HB3 [ ] Yes[ ] No
POLIO 1 [ ] Yes[ ] No
2. Does the child have Growth Chart/ Mother and POLIO 2 [ ] Yes[ ] No
Child Health Care book: POLIO 3 [ ] Yes[ ] No
A. [ ] Yes POLIO 4 [ ] Yes[ ] No
B. [ ] No Rubeola [ ] Yes[ ] No

3. Does the child get Vit. A in the last 6 months: 6. Was the child given initial colostrum/first milk?
A. [ ] Yes A. [ ] Yes
B. [ ] No B. [ ] No

4. Has the child weighed in the last 3 months? 7. When was the first time the child given weaning
A. [ ] Yes food:
B. [ ] No A. [ ] Since birth
B. [ ] < 4 months
C. [ ] 4 or 5 months old
D. [ ] Over 6 months old
E. [ ] Stil given breastmilk

FORM 3
PREGNANT WOMAN

01. Age: 5. Do you get any TT (tetanus toxoid) vaccination during

Gestation: the pregnancy?
0-12 week(s) A. [ ] Yes
13-24 weeks B. [ ] No
25-36 weeks
6. Have you ever checked your hemoglobin during the
More than 36 weeks
pregnancy?
A. [ ] Yes
2. History of previous pregnancy(ies):
B. [ ] No
No Cases Yes No
2.1 Abortus 7. Have you got blood booster pills (Fe tablets)?
2.2 Anemia A. [ ] Yes, taken as prescribed
2.3 Hiperemisis B. [ ] Yes, taken sometimes
2.4 Twin C. [ ] Yes, was not taken
2.5 Convulsive movement D. [ ] No

3. much is the increase in body weight (BW) during 8. Do you experience the following complains during the
the current pregnancy? pregnancy? (allowing more than one answer)
A. [ ]< 9 kg No Complains Yes No
B. [ ] 9-12 kg 8.1 Nausea and vomiting
C. [ ]> 12 kg 8.2 Headache and dizziness
8.3 Uncontrol weight increase
4. Do you get any antenatal cares from health 8.4 Being weak/fatigue
personnels? 8.5 Swollen/numb feet
A. [ ] Yes
8.6 Heartburn
B. [ ] No
8.7 Vaginal discharge

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 FORM 4
POSTPARTUM MOTHER

Respondent Identity 5. Do you get any information about care in postpartum

Age: ………. years phase:
1st/2nd/3rd/4th/...etc.born child A. [ ] Yes
B. [ ] No
1. Place of delivery
A. Health facilities 9. Do you experience the following complains? (allowing
B. Non-health facilities more than one answer) postpartum
No Complains Yes No
2. Was the baby given early initiation of 9.1 Headache
breastfeeding immediately after birth? 9.2 Being exhausted and very
A. [ ] Yes weak
B. [ ] No 9.3 Often getting fever
9.4 Feeling sad with unknown
3. Postpartum care attendace: cause
A. [ ] Health personnels 9.5 Constipation
B. [ ] Non-health personnels 9.6 Bleeding
6.7 Having bone pain
4. Do you get Vit. A in the postpartum period:
A. [ ] Yes
B. [ ] No

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 FORM 5
FAMILY DENTAL HEALTH

1. Is/are there any family member(s) having cavities?

A. [ ] Yes
B. [ ] No

2. Is/are there any family member(s) having gum infection?

A. [ ] Yes
B. [ ] No

3. Is/are there any family member(s) wearing false tooth(teeth)?

A. [ ] Yes
B. [ ] No

4. Teeth brushing time in the family

A. [ ] After breakfast and before going to bed
B. [ ] During morning and afternoon bath
C. [ ] Every time after meals

5. Teeth brushing habit in the family

A. [ ] Every day
B. [ ] We do when we remember
C. [ ] Other answers (mention:.......................................)

6. Do you and other family members do annual dental check up?

A. [ ] Yes
B. [ ] Not always
C. [ ] Never

7. Why do you and othe family members visit dental clinic?

A. [ ] Having dental problem
B. [ ] Routine checkup

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 FORM 6

SMOKING BEHAVIOUR

1. Is/are there any family member(s) who is/are smoking?

A. [ ] Yes (proceed tonumber 2)
B. [ ] No (end here)

2. Do/does he/she/they smoke inside the house?

A. [ ] Yes
B. [ ] No

3. Is cigaratte served in certain occasions in the community?

A. [ ] Yes
B. [ ] No

4. When does the family member(s) smoke mostly?

A. [ ] In the morning
B. [ ] At noon-time
C. [ ] In the afternoon
D. [ ] In the evening/night

5. How many family members who are smoking?

A. [ ] 1 person
B. [ ] 2 person
C. [ ] 3 (mention who:…………………………….)
D. [ ] > 3(mention who:…………………… ……)

6. How do other family members react when he/she/they is/are smoking?

A. Not supporting
B. Not really supporting
C. Quite supporting
D. Supporting

7. Is there any prohibition against smoking in and around the house?

A. [ ] Yes
B. [ ] No

*******The end*******

27. Apakah ada anggota keluarga yang merokok?

a. Ya b. Tidak

28. Apakah anggota keluarga merokok didalam rumah?

a. Ya b. Tidak c. Tidak ada yang merokok

29. Berapa orang anggota keluarga yang merokok?

a. 1 orang (sebutkan :…………………………….)
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b. 2 orang (sebutkan :…………………………….)
c. 3 orang (sebutkan :…………………………….)
d. > 3 orang (sebutkan……………………………)