The shaded area to be filled by the interviewer
(For office Use)
Interviewer code Area Code
Questionnaire Number
.........................
.................
...............................
R1.......
R3.......
Date:
Day Month Year
The following information to beilled by the interviewer
Name of interviewer:...............................................
Gender:
1. Male 2. Female
R4.......
City/village/camp:.............................
Selected Street:.............................
Time of the interview:
Hour Minute
For office use only:
Field supervisor...........................
Coder...........................
Code reviwer...........................
Signature of interviewer:....................
How many people 18 years or older living in this household?
------------------
How many of those are women?
------------------
Number of adults in household
| One adult | Two adults | Three adults | Four + | ||
| None | Adult
1 |
Oldest
3 |
Middle aged
6 |
2nd Oldest male
10 |
|
| Number of
Women |
One woman | Adult
2 |
Male / Female
4 |
Youngest male
7 |
Middle aged male
11 |
| Two women | Youngest female
5 |
Oldest Female
8 |
Oldest/youngest male
12 |
||
| Three women | Middle aged female
9 |
Middle aged female
13 |
|||
| Four women | 2nd youngest female
14 |
R5.....................
| Question | Value | Code | |
| 1.
|
Are you a refugee or descendant of a refugee family?
|
1. Yes
2. No (Go to Q.5) 3. D'K 9. No answer |
C1 |
| 2.
|
If yes, are you...
|
1. first generation refugee
2. Second generation refugee 3. Third generation refugee 4.Other 5. D'K 8. Not applicable 9. No answer |
C2 |
| 3a.
|
When did you become a refugee?
|
1. 1948
2. 1967 3. 1948 and in 1967 4. Other 5. D'K 8. Not applicable 9. No answer |
C3a |
| 3b.
|
When did your immediate family become refugees?
|
1. 1948
2. 1967 3. 1948 and in 1967 4. Other 5. D'K 8. Not applicable 9. No answer |
C3b |
| 4. | Do you have an UNRWA card? | 1. Yes
2. No 8. Not applicable 9. No answer |
C4 |
| 5. | From which village or town do you or your nuclear family originally come from? | C5 | |
| 6. | In which village or town are you a resident?
(Interviewer: !!! Place of residence is not place of living!) |
C6 |
|
| 7. | In which village or town does your family live? | C7 | |
| 8.
|
Are you currently employed or not?
|
1. I am employed full-time
2. I am employed part-time 3. I am not employed 4. I am a house wife (Go to Q.14) 5. I am a student (Go to Q.14) 6. I am retired |
C8 |
| 9. | Occupation | 1. Professional
2. Skilled worker 3. Unskilled worker 4. Technician 5. Employee 6. Other 88. Not applicable 99. No answer |
C9 |
| 10. | In which village or town do you work ? | C10 | |
| 11. | Place of work
|
1. Settlement
2. Israel proper 3. West Bank 4. Gaza Strip 5. Jerusalem 6. Other 7. Do not work 8. Not applicalbe 9. No answer |
C11 |
| 12. | Did your employment situation change during the past three months? | 1. No, it remained the same (Go to Q.14)
2. I had to search for a different employement 3. I lost my job 8. Not applicable (Go to q.14) 9. No answer (Go to Q.14) |
C12 |
| 13. | Was this change a consequence of the current situation? | 1. Yes
2. No 8. Not applicable 9. No answer |
C13 |
| 14. | How many people live in this household, including childre (below 18)? |
99. No answer |
C14 |
| 15. | How many of those are employed? |
99. No answer |
C15 |
| 16. | How many of the employed are women? |
99. No answer |
C16 |
| 17. | How many of your household members have lost their jobs in the past three months? | C17 | |
| 18. | How many of your household members have lost their jobs in the past three months because of the current situation? |
0. None (if None, Go to Q.19) 99. No answer (Go to Q.19) |
C18 |
| 18a. | Where did those who lost there jobs because of the current
situation work?
(Number of persons) |
West Bank ------ 88. Not applicable
Gaza -------- 88. Not applicable Jerusalem --------- 88. Not applicable Settlements ---------- 88. Not applicable Israel -------- 88. Not applicable |
C18a
C18b C18c C18d C18c |
| 19. | To what extent would you say that restrictions on your mobility were a problem for you and your family in the past three months? | 1. A lot
2. A little 3. Not at all 8. D'K 9. No answer |
C19 |
| 20. | Have you noticed anything on the children's behavior since the begining of the Intifada? | 1. Yes (Go to Q. 21)
2. No (Go to Q.22) 9. No answer |
C20 |
| 21. | What kind of change did you notice? | 1. Frequent nightmares
2. Sleeping disturbances 3. Bed wetting 4. Concentration difficulties 5. Other (specify)____________ 88. Not applicable 99. No answer |
C21 |
| 22. | Please answer yes or no if you or your family has incurred any of the following injuries? | ||
| 22-1 | Has any of your family or the relatives of your family martyred in the past four months? | 1. Yes
2. No 9. No answer |
C22a |
| 22-2 | Has any of your relatives been injured in the past four months? | 1. Yes
2. No 9. No answer |
C22b |
| 22-3 | Has any of your property or your family's property been damaged in the past four months? | 1. Yes
2. No 9. No answer |
C22c |
| 22-4 | Where any trees been uprooted for you or for your family in the past four months? | 1. Yes
2. No 9. No answer |
C22d |
| 22-5 | Did your business or that of your family suffer in the past four months? | 1. Yes
2. No 9. No answer |
C22e |
| 23. | Have you or your family received any assistance from any party since the Intifada al Aqsa started in late September? | 1. Yes
2. No I did not receive any assistance, financial or non financial (Go to Q.26) 3. I am not sure 8. I do not know (Go to Q.26) 9. No answer (Go to Q.26) |
C23 |
|
|
|
|
|
| 1st Type: ____________
88. Not applicable
|
________NIS
[0] No value
|
______: ________
88. Not applicable
|
[1]Very satisfied
[2] Satisfied [3] Dissatisfied [4] Very dissatisfied [5] DK [6] Not applicable [9] No answer |
| C24a1 | C24b1 | C24c1 | C24d1 |
| 2nd Type: ____________
88. Not applicable
|
________NIS
[0] No value
|
______: ________
88. Not applicable
|
[1]Very satisfied
[2] Satisfied [3] Dissatisfied [4] Very dissatisfied [5] DK [6] Not applicable [9] No answer |
| C24a2 | C24b2 | C24c2 | C24d2 |
| 3rd Type: ____________
88. Not applicable
|
________NIS
[0] No value
|
______: ________
88. Not applicable
|
[1]Very satisfied
[2] Satisfied [3] Dissatisfied [4] Very dissatisfied [5] DK [6] Not applicable [9] No answer |
| C24a3 | C24b3 | C24c3 | C24d3 |
| 4th Type: ____________
88. Not applicable
|
________NIS
[0] No value
|
______: ________
88. Not applicable
|
[1]Very satisfied
[2] Satisfied [3] Dissatisfied [4] Very dissatisfied [5] DK [6] Not applicable [9] No answer |
| C24a4 | C24b4 | C24c4 | C24d4 |
| 25. | In general, how do you evaluate the assistance provided to you and to your family during the last three months by various governmental, non-governmental, and international organizations? | 1. Very satisfied
2. Satisfied 3. Dissatisfied 4. Very dissatisfied 5. DK 8. Not applicable 9. No answer |
C25 |
| 26. | If neither you nor your family received any assistance, would you say that you need assistance? | 1. Yes
2. No 3. Not sure 4. We did not receive assistance |
C26 |
| 27. | Regardless of whether you receive or do not receive assistance, what is the most important need would you say you require? | Most important need: _________________ | C27 |
| 28. | How much money would you say your household needs every month to be able to meet the basic life necessities? | _________ Shekel.
[99] No answer |
C28 |
| 29. | To what extent would you say your household income is close to this number nowdays? | 1. Much higher than this
2. Little higher than this 3. About the same 4. Little less than this 5. Much less than this 8. DK 9. No answer |
C29 |
| 30. | Do you know of any projects that were carried out in your community since the Intifada al Aqsa started? | 1. Yes I do
2. No I do not (Go to Q. 32) 9. No answer (Go to Q.32) |
C30 |
| 31. | If yes, what are they? | [99 Not applicable
[99] No answer |
C31 |
| 32. | Do you or your family regularly benefit from any assistance, such as education and health, from UNRWA? | 1. Yes
2. No (Go to Q.34) 8. I do not know (Go to Q.34) 9. No answer (Go to Q.34) |
C32 |
| 33. | In general, how satisfied are you with the services provided by UNRWA? | 1. Very satisfied
2. Satisfied 3. Dissatisfied 4. Very dissatisfied 8. I do not know 9. No answer |
C33 |
| 34. | What kind of relief do you think is needed for the community
you live in?
(only the most important ONE) |
______________
[55] I do not know
|
C34 |
| 35. | For each of the following services, please rate its importance in the current crisis? | ||
| 35-1 | The importance of education in the current situation? | [1] Very high
[2] High [3] Medium [4] Low [5] Very low [6] Do not know [9] No answer |
C35a |
| 35-2 | The importance of health in the current situation? | [1] Very high
[2] High [3] Medium [4] Low [5] Very low [6] Do not know [9] No answer |
C35b |
| 35-3 | The importance of food distribution in the current situation? | [1] Very high
[2] High [3] Medium [4] Low [5] Very low [6] Do not know [9] No answer |
C35c |
| 35-4 | The importance of finding employment in the current situation? | [1] Very high
[2] High [3] Medium [4] Low [5] Very low [6] Do not know [9] No answer |
C35d |
| 35-5 | The importance of infrastructure (such as building roads, sewage, etc.) in the current situation? | [1] Very high
[2] High [3] Medium [4] Low [5] Very low [6] Do not know [9] No answer |
C35e |
| 36. | For each of the following, services, please rate its effectiveness in the current situation? | ||
| 36-1 | The effectiveness of education in the current situation? | [1] Very effective
[2] Effective [3] Not effective enough [4] Not effective at all [5] Do not know [9] No answer |
C36a |
| 36-2 | The effectiveness of Health in the current situation? | [1] Very effective
[2] Effective [3] Not effective enough [4] Not effective at all [5] Do not know [9] No answer |
C36b |
| 36-3. | The effectiveness of food distribution in the current situation? | [1] Very effective
[2] Effective [3] Not effective enough [4] Not effective at all [5] Do not know [9] No answer |
C36d |
| 36-4 | The effectiveness of finding employment in the current situation? | [1] Very effective
[2] Effective [3] Not effective enough [4] Not effective at all [5] Do not know [9] No answer |
C36e |
| 36-5 | The effectiveness of infrastructure (such as building roads, sewage, etc.) in the current situation? | [1] Very effective
[2] Effective [3] Not effective enough [4] Not effective at all [5] Do not know [9] No answer |
|
| 37 | Which Palestinian political or religious faction do you trust most? |
No one (Do not read) Refuse to answer |
C37 |
| 38. | Your age | -------- Years | C38 |
| 39. | Educational level | [1] Illiterate
[2] Until element. [3] Until Prep. [4] Until second [5] Some college [6] College & above [9] No answer |
C39 |
| 40. | If the average income of a family is around 3,000 shekels per month, how much is your family income? | [1] Much higher than average
[2] Little higher than average [3] Close to average [4] Little less than average [5] Much less than average [9] DK/NA |
C40 |
| 41. | Married Status | [1] Single
[2] Married [3] Divorced [4] Widower [9] No answer |
C41 |
| 42. | Area | [1] West Bank
[2] Jerusalem [3] Gaza Strip |
C42 |
| 43. | Residence | [1] City [2] Camp [3] Village | C43 |
| 44. | Gender | [1] Male [2] Female | C44 |