BIGPIC SOCIAL NETWORK SURVEY
Demographics
AMRS ID Number:
Family Name:
Given Name:
Middle Name:
Gender:
...
Male
Female
Date Of Birth:
Encounter Details
AMPATH Facility:
*
Name of Interviewer:
*
Interviewer ID:
*
Interview Date:
*
SECTION A - PARTICIPANT INFORMATION
Enter Participant ID:
*
BIGPIC Group ID:
*
SECTION B - IMPORTANT MATTERS
How many people do you talk to most frequently about important matters (Give at most 5 people)
*
Please provide the following information about the
people you talk to most frequently about
important matters
.
Person 1
Name of person:
*
Refused
How do you know
?
*
...
Immediate family member
Extended family member
Friend
Neighbor
Work mate
Other
Specify Other:
*
Is
Male or Female?
*
...
Male
Female
How long have you known him/her?
Years:
*
Months:
*
Don't Know
Refused
How often do you speak with him/her?
*
...
Never
At least every couple of months
At least monthly
At least weekly
Daily
Refused
Please indicate which groups or organization you participate in together (select all that apply).
*
Church
Work
Club
GMV
Microfinance
Other
Specify other group:
*
None
SECTION C - HEALTH MATTERS
How many people do you talk to most frequently about health matters (Give at most 5 people)
*
Please provide the following information about the
people you talk to most frequently about
health matters
.
Person 1
Name of person:
*
Refused
How do you know
?
*
...
Immediate family member
Extended family member
Friend
Neighbor
Work mate
Other
Specify Other:
*
Is
Male or Female?
*
...
Male
Female
How long have you known him/her?
Years:
*
Months:
*
Don't Know
Refused
How often do you speak with him/her?
*
...
Never
At least every couple of months
At least monthly
At least weekly
Daily
Refused
Please indicate which groups or organization you participate in together (select all that apply).
*
Church
Work
Club
GMV
Microfinance
Other
Specify other group:
*
None
SECTION D - MICROFINANCE GROUP
For UC Arm or GMV Arm - do you belong a
microfinance group
?
*
...
Yes
No
Refused
For MF group, how many people (up to 7) do you talk to most often within the microfinance group?
*
For the Number of people provided above, Please list their names below and provide the following scales.
Person 1
First and Last Name:
*
Do you talk to this person outside of group meetings?
*
...
Yes
No
Refused
On a scale from 1 to 4, how close do you feel to this person?
*
...
1 = Not at all close
2 = Somewhat close
3 = Very close
4 = Extremely close
On average, how often do you talk to this person about
health-matters
?
*
...
Never
At least every couple of months
At least monthly
At least weekly
Daily
Refused
In my microfinance group, I...
I feel a sense of belonging to my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel that I am a member of my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I see myself as part of my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am enthusiastic about my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am happy to be in my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My group is one of the best microfinance programs anywhere:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
SECTION E - GROUP MEDICAL VISIT GROUP
Do you belong a
group medical visit group
?
*
...
Yes
No
Refused
Don't know
Please specify where/type:
*
For GMV group, how many people (up to 7) do you talk to most often within the group medical visit group?
*
For the Number of people provided above, Please list their names below and provide the following scales.
Person 1
First and Last Name:
*
Do you talk to this person outside of group meetings?
*
...
Yes
No
Refused
On a scale from 1 to 4, how close do you feel to this person?
*
...
1 = Not at all close
2 = Somewhat close
3 = Very close
4 = Extremely close
On average, how often do you talk to this person about
health-matters
?
*
...
Never
At least every couple of months
At least monthly
At least weekly
Daily
Refused
In my group medical visit group, I...
I feel a sense of belonging to my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel that I am a member of my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I see myself as part of my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am enthusiastic about my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am happy to be in my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My group is one of the best microfinance programs anywhere:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
SECTION F - CLUBS, GROUPS, CHURCHES
Do you belong any
clubs, groups, or churches
?
*
...
Yes
No
Refused
Please specify which club/group/church:
*
How many people(up to 7) do you talk to most often within the clubs, group or churches? (Give at most 7 people)
*
For the Number of people provided above, Please list their names below and provide the following scales.
Person 1
First and Last Name:
*
Do you talk to this person outside of group meetings?
*
...
Yes
No
Refused
On a scale from 1 to 4, how close do you feel to this person?
*
...
1 = Not at all close
2 = Somewhat close
3 = Very close
4 = Extremely close
On average, how often do you talk to this person about
health-matters
?
*
...
Never
At least every couple of months
At least monthly
At least weekly
Daily
Refused
In this club/group/church, I...
I feel a sense of belonging to my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I feel that I am a member of my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I see myself as part of my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am enthusiastic about my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
I am happy to be in my group:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
My group is one of the best programs anywhere:
*
...
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree