public disclosure authorized 69588 v 3 gds2 survey...

Governance and Decentralization Survey (GDS)

GDS2 Survey Instrument

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69588 v 3

CONFIDENTIAL

GOVERNANCE AND DECENTRALIZATION SURVEY 2

H O U S E H O L D

HOUSEHOLD ID └─┴─┘└─┴─┘ 11 └─┴─┘

Name Address

OUTCOME FROM VISITS

First Visit Second Visit Third Visit

Date └─┴─┘/└─┴─┘/ 2006 └─┴─┘/└─┴─┘/ 2006 └─┴─┘/└─┴─┘/ 2006 Start Time └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ Finish Time └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ Visit Outcome 1. Finished

2. Partly Finished, _____________________ 3. Respondent refused/unavailable/hindered

1. Finished 2. Partly Finished, _____________________ 3. Respondent refused/unavailable/hindered

1. Finished 2. Partly Finished, _____________________ 3. Respondent refuses/unavailable/hindered

ENUMERATOR, EDITOR AND SUPERVISOR

Enumerator Editor Subdistrict Supervisor

Name/Code _________________________ / └─┴─┴─┘ _________________________ / └─┴─┴─┘ _________________________ / └─┴─┴─┘ VERIFICATION OUTCOME

Verification by Subdistrict Supervisor Monitor by Subdistrict Supervisor Verification by Editor

1. Verified, without error 2. Verified and Corrected 3. Verified, without correction, ______________________ 4. Unverified, _____________________________________

1. Yes 3. No

1. Data entered, without error 2. Data entered and corrected 3. Data entered, without correction,__________________ 4. Data unentered, manually edited,____________________ 5. Data unentered, unedited, __________________________

Household

HOUSEHOLD LOCATION SKETCH INTERVIEWER REMARKS: MAKE A SIMPLE SKETCH/MAP OF THE HOUSEHOLD LOCATION BY MARKING NAMES OF ROAD, PLACES AND/OR BUILDINGS OR SUCH THAT EASILY RECOGNIZED AND ESTIMATED TO LAST LONG (NOT EASILY DAMAGED, ALTERED OR GONE). DESCRIBE THE PLACES OR BUILDINGS THAT EASILY RECOGNIZED AND WOULD LAST LONG (SUCH AS VILLAGE OFFICE, LARGE MOSQUE, BRIDGE, SCHOOL, CEMETERY, ETC) AS MARKERS THAT BECOME THE “CENTER POINTS” IN THE SKETCH. PROVIDE EXPLANATION AND INFORMATION (SUCH AS LEGEND IN MAP) IF NECESSARY.

A. HOUSEHOLD LOCATION

Household

1. Province Code └─┴─┘ 2. District/city *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/kelurahan *) Code └─┴─┴─┘ 5. Hamlet/Equivalent Code 1 2 6. Address

7. Postal Code └─┴─┴─┴─┴─┘ 8. Home Telephone and/or Handphone Number a. Home 1. Available, └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 3. Unavailable

b. Cellular phone 1. Available, └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─ 3. Unavailable *) Select One B. HOUSEHOLD ROSTER INTERVIEWER REMARKS: CHOOSE AN ANSWER FOR HOUSEHOLD ROSTER

No.3 How is this person related to the Head of Household (KRT) No.6 Ethnicity No.9 Highest level of education completed

1. Head of Household 2. Husband/Wife 3. Biological Children 4. Foster/Adopted Children 5. Children-in-law 6. Parents/Parents-in-law

7. Siblings 8. Siblings-in-law 9. Grandchildren 10. Grandparents 11. Other relatives (cousin,

niece/nephew, etc.) 12. Non-relatives (maid, driver,

etc.)

1. Java 2. Sunda 3. Bali 4. Batak 5. Bugis 6. Chinese 7. Madura 8. Sasak

9. Minang 10. Banjar 11. Bima-Dompu 12. Makassar 13. Nias 14. Palembang 15. Sumbawa 16. Toraja

17. Betawi 18. Dayak 19. Melayu-Deli 20. Komering 21. Ambon 22. Manado 23. Aceh 95. Others, _______________

1. Elementary/Islamic Elementary (MI)

2. Junior High/Islamic Junior high (MTs)

3. HighSchool/SMK/Islamic High School (MA)

4. Diploma I/II 5. Diploma III 6. Diploma IV/S1/Bachelor 7. Post Graduate (S2/S3) 95. Others, _______________

Household

INTERVIEWER REMARKS: A HOUSEHOLD IS A GROUP OF PEOPLE LIVING UNDER THE SAME ROOF, EATING IN THE SAME KITCHEN, AND DECIDE ECONOMICAL DECISION TOGETHER, START FROM THE HEAD OF HOUSEHOLD (KRT), KRT PARTNER, CHILDREN, CHILDREN IN LAW, GRANDCHILDREN, ECT.

1. HH member number

2. Household/HH Member’s complete name?

3. Relation with Head of household?

4. Gender?

M F

5. Religion? 1. Moslem 2. Catholic 3. Christian 4. Buddhist 5. Hindu 95.Others, _____

6. Ethnicity?

7. Age? (years)

8. School enrollment? 1. Have never/not

yet enrolled to any school NO.11

2. Still in school 3. No longer in

school

9. Highest level of education completed?

10. Highest level/class completed? 1. 1 5. 5 2. 2 6. 6 3. 3 7. Finished 4. 4 8. Unfinish

11. Last year, did this person work at any time? 1. Yes 3. No

1.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

2.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

3.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

4.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

5.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

6.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

7.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

8.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

9.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

10.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

C. HOUSEHOLD CHARACTERISTICS

Household

C1. General

1. Is the head of household able to read an Indonesian newspaper? 1. Yes 3. No

2. Is the head of household able to write a letter in Bahasa Indonesia? 1. Yes 3. No

3. Where was the head of household born? 1. In this village/kelurahan 4. In other provinces, _________________ 2. In a different village/kelurahan within 5. Abroad

the same district/city 8. DO NOT KNOW 3. In a district/city in the same province

4. How long has the head of household lived in this village/kelurahan? └─┴─┘ years

5. Which customs/traditions that most frequently used in the daily live of this household? 1. Java 8. Sasak 15. Sumbawa 22. Manado 2. Sunda 9. Minang 16. Toraja 23. Aceh 3. Bali 10. Banjar 17. Betawi 24. Indonesia 4. Batak 11. Bima-Dompu 18. Dayak 95. Others, ________________ 5. Bugis 12. Makasar 19. Melayu Deli 6. Chinese 13. Nias 20. Komering 7. Madura 14. Palembang 21. Ambon

6. What is the common language used in this house? 1. Java 7. Madura 13. Nias 19. Lampung 2. Sunda 8. Sasak 14. Palembang 20. Dayak 3. Bali 9. Minang 15. Sumbawa 21. Indonesia 4. Batak 10. Banjar 16. Toraja 95. Others, _________________ 5. Bugis 11. Bima 17. Lahat 6. Chinese 12. Makasar 18. Betawi

7. Are you or other HH member currently holding the position or was holding position as:

a. Civil servant (including police and military) 1. Yes 3. No

b. Village Head/Lurah 1. Yes 3. No

c. Members of Village Legislature (BPD/LMD or LKMD/LKMK/LPM) 1. Yes 3. No

d. Religious, customary or community figures (e.g: the eldest or respected of the village) 1. Yes 3. No

8. Does this household own a health subsidy card such as Health Card/JPS Health Card/Gakin Card/ Askeskin Card or others?

1. Yes 7. REFUSE TO ANSWER NO.10 3. No NO.10

9. Has the card ever been used in [….]?

a. Community Health Center (Puskesmas) 1. Yes 3. No 8. DO NOT KNOW

b. Hospital 1. Yes 3. No 8. DO NOT KNOW

Household

10. Have you or other HH member ever proposed a Statement of Poor (SKTM) from the village office/kelurahan to get waiver of [….]?

a. Health Cost 1. Yes 3. No 7. REFUSE TO ANSWER

b. Education Cost 1. Yes 3. No 7. REFUSE TO ANSWER

11. Does this household own SLT (Unconditional Cash Transfer) Card or KKB (Fuel Compensation Card)?

1. Yes 3. No 7. REFUSE TO ANSWER

C2. Household Dwelling Characteristic

1. What is the material used for most part of the roof on this house?

1. Concrete 4. Zinc 95. Others, ______________ 2. Roof-tile 5. Asbestos 3. Shingle 6. Palm fiber/Sago palm

2. What is the main material used for most part of walls in this house? 1. Wall 3. Bamboo 2. Wood 5. Others, ____________________________

3. What is the flooring material used for most part of this house? 1. Soil 2. Non soil

4. What is the total floor area in this house? └─┴─┘.└─┴─┴─┘ m2 5. What is the lighting source for this house? 1. National Electricity Company (PLN) 4. Oil lamp/flashlight/torch

2. Non-PLN Electricity 5. Others, ____________________________ 3. Petromax(Kerosene Lamp)

6. What is the potable water source that most frequently used by the household for drinking and cooking?

1. Water utilities(PAM)/piped water into dwelling/yard/plot 2. Public tap/standpipe 3. Drilled well 4. Protected dug well 5. Protected spring 6. Rainwater collection 7. Bottled water 8. Unprotected dug well 9. Unprotected spring 10. Water vendor truck 11. Surface water (river, stream, dam, lake/fishpond, channel, water channel)

7. What type of toilet that most frequently used by this household?

1. Family toilet 3. Public toilet 2. Shared toilet 5. Others NO.9

8. What type of latrine used? 1. Pour flush latrine 3. Pit latrine/cubluk

Household

2. Throne latrine

9. Where is faeces final disposal?

1. Septic Tank/SPAL 4. Open pit hole 2. Pond/rice fields 5. Coast/field/garden 3. River/lake/sea 95. Others, _____________________________

D. HEALTH We are now discussing health issues. D1. Access to Health Facilities

INTERVIEWER REMARKS: SECTION D1 AIMS TO ASK RESPONDENT’S KNOWLEDGE AND/OR EXPERIENCE OF HEALTH FACILITIES IN HER/HIS DISTRICT. IF THE RESPONDENT HAS INFORMED OF MORE THAN ONE FACILITY, PLEASE REFER TO THE NEAREST HEALTH FACILITY TO THE RESPONDENT’S HOUSE.

Facilities 1. Are you aware of the existence of [….]?

1. Yes 3. No

2. What is the name and location of [...]?

3. What kind of transportation used to reach [...]? A. On foot D. Car B. Bicycle E. Boat C. Motorcycle V. Others, ________

4. How long does it take from your house to [...]?

(CONVERT TO MINUTES)

5. Have you and/or other HH member ever used the facility [...]?

1. Yes 3. No

a. Public Hospital (RSUP, RSUD, RS BUMN, RS TNI/Polri)

1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

b. Community Health Center (Puskesmas) 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

c. Community Health Subcentre (Pustu) 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

d. Village Maternity Post (Polindes) 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

e. Mobile Puskesmas/Floating Puskesmas 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

f. Private Hospital 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

g. Private Clinic 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

h. Private Doctor (general/specialist/dentist) 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

i. Private Nurse/Medical aide 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

j. Private Midwife 1 3 A B C D E V _____________________ └─┘.└─┴─┴─┘ 1 3

Household

D2. The Health Facility Recently Used by Household Member

We would like to ask you or other HH member’s experience on your most recent visit to the health facility. INTERVIEWER REMARKS: TRY TO ASK THE FOLLOWING QUESTIONS TO HH MEMBER WHO USES THE HEALTH FACILITY MENTIONED.

1. When was the last time you or other HH member used the health facility? 1. Last week 5. Less than one year ago 2. Less than one month ago 6. 1–2 years ago 3. Less than three months ago 7. More than 3 years ago SECTION D3 4. Less than six months ago 8. HAS NEVER USED IT SECTIOND5

2. Who (which HH member) received the health facility at that time? INTERVIEWER REMARKS: CHECK THE HH MEMBER NUMBER ON SECTION B └─┴─┘

1. Public Hospital 6. Private Hospital 2. Community Health Center/Puskesmas 7. Private Clinic 3. Community Health Subcentre (Pustu) 8. Private Doctor 4. Village Maternity Post (Polindes) 9. Private Midwife 5. Mobile/FloatingPuskesmas (Pusling) 10. Private Nurse

3. What was the health facility you or other HH member used at that time? INTERVIEWER REMARKS: IF THE RESPONDENT ANSWERS HOSPITAL THEN MAKE

SURE WHETHER IT IS A PUBLIC OR PRIVATE HOSPITAL. IF IT IS PUSKESMAS, MAKE SURE IF IT IS A PUSKESMAS OR A PUSTU.

a. Name: ________________________________________________________________________ b. Location:

______________________________________________________________________

INTERVIEWER REMARKS: QUESTION NO.4 ASK WHETHER THE FAMILY OWN A HEALTH SUBSIDY CARD (IF SECTION C1 NO.8 = YES) AND THE RESPONDENT DOES NOT USE THE GOVERNMENT HEALTH FACILITY (PUBLIC HOSPITAL, PUSKESMAS, PUSTU, POLINDES, PUSLING). 4. Why are you or other HH member not using the government health facility, such as public

hospital, Puskesmas, Polindes, etc)?

A. DISTANT B. LIMITED SERVICE TIME C. LIMITED FACILITY (MEDICAL & HUMAN RESOURCES, TOOLS AND FACILITY) D. DO NOT RECEIVE PROPER SERVICES V. OTHERS,

_____________________________________________________________________ W. NOT APPLICABLE

5. Where was the health service delivered? 1. In health facilities 2. In HH member house

6. What was the purpose of this person or other HH member of using the health facility? A. General medication, ________________________ B. KIA/Mother and Child Care, KB/Family Planning, pre-natal care C. Immunization D. Dental care V. Others, ____________________________

7. How long must you, or other HH member, wait before receiving services (for example: since entering the facility until receiving services, or since calling the doctor or other medical officer until the arrival at the respondent’s house)?

└─┘.└─┴─┴─┘ minutes

Household

8. Who provided the health services? INTERVIEWER REMARKS: IF THERE ARE 2 MEDICAL OFFICERS OR MORE WHO

PROVIDE THE SERVICE, PLEASE CHOOSE THE ONE WITH THE MOST SENIOR POSITION.

1. Doctor 3. Nurse/Paramedic 2. Midwife 5. Others, ____________________________

9. How long did the doctor or other medical officer examine the respondent? └─┴─┴─┘ minutes 10. Was the service faster, in accordance with, or slower than what you or other HH member

expected? 1. Faster 2. In accordance with 3. Slower

11. Did the doctor or other medical officers advised you or other HH member to take laboratory tests (such as blood test, etc)?

1. Yes 3. No 8. DO NOT KNOW

12. How much was the total cost that you or other HH member should pay for services (excluding transportation costs)

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

13. Did the costs include medicine costs and/or injections? 1. Yes 3. No 8. DO NOT KNOW

14. During your or other HH member visit, did you experience discrimination in term of the service delivery?

1. Yes 3. No

15. During service delivery, did you or other HH member received any unpleasent/rude/hostile manner?

1. Yes 3. No

16. What was your or other HH member’s reason for choosing this particular health facility from other health facilities that provide similar services?

INTERVIEWER REMARKS: AVOID ANSWERS SUCH AS GOOD OR SUITABLE HEALTH

SERVICES, ETC. IF THE RESPONDENT REPLIES WITH SUCH ANSWER, PLEASE TRY TO PROBE TO GET INFORMATION REGARDING THEIR DEFINITION OF GOOD SERVICES, THEN CATEGORIZE IT INTO ONE OF THE OPTIONS.

A. COMPLETE FACILITY (MEDICAL OFFICER, TOOL AND FACILITY) B. SERVICE AVAILABLE WHEN NEEDED C. CLOSE TO HOME D. CHEAP E. EFFECTIVE MEDICINE F. COURTESY OF THE STAFF V. OTHERS, _____________________________________________________________________

Household

D3. Health Facility That Most Frequently Used We would like to ask which health facility that you or other HH member most frequently used.

1. Public Hospital 7. Private Clinic 2. Community Health Center/Puskesmas 8. Private Doctor 3. Community Health Subcentre (Pustu) 9. Private Midwife 4. Village Maternity Post (Polindes) 10. Private Nurse 5. Mobile/Floating Puskesmas (Pusling) 96. NEVER IN THE LAST 5 YEARS D5 6. Private Hospital

1. What kind of health facility that you or other HH member most frequently used?

a. Name :________________________________________________________________________ b. Location: 1. Within the Village SECTION D4 2. Outside the village

2. Why do you choose the health facility outside the village/kelurahan? […]? A. NO FACILITY AVAILABLE IN THIS VILLAGE/KELURAHAN B. THE QUALITY OF HEALTH FACILITY IN THIS VILLAGE/KELURAHAN IS LOWER THAN THE

ONE OUTSIDE THE VILLAGE/KELURAHAN. C. THE HEALTH SERVICE FACILITY IN THIS VILLAGE/KELURAHAN IS MORE EXPENSIVE

COMPARED TO THE ONE OUTSIDE THIS VILLAGE/KELURAHAN. V. OTHERS, _____________________________________________________________________

D4. Assessment on Health Services We would like to ask for your opinion on health services in ____ (THE HEALTH FACILITY THAT MOST FREQUENTLY USED OR SEE ANSWER IN SECTION D3 NO.1)

1. In general, according to you, how is the current health services in____ (ANSWER SECTION D3 NO.1) compared to the services two years ago?

1. Improved 6. NOT APPLICABLE NO.3 2. THE SAME 8. DO NOT KNOW NO.3 3. Deteriorated

2. According to you how is the current [...] in ___ (ANSWER SECTION D3 NO.1) compared to 2 years ago?

a. Condition of the health service venue INTERVIEWER REMARKS: ROOM CONDITION, ROOM CLEANLINESS, ETC.

1. Improved 3. Deteriorated 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

b. Attentiveness of the health officers INTERVIEWER REMARKS: COURTESY, ACCOMODATIVE/SUPPORTIVE, ETC.


c. Health services costs 1. More affordable 3. More unaffordable 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

d. Medicine and vaccine supply 1. Improve/available 3. Deteriorate/unavailable 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

e. Waiting time 1. Shorter 3. Longer 8. DO NOT KNOW

Household

2. THE SAME 6. NOT APPLICABLE

3. What is the most important aspect to be improved in ____ (ANSWER SECTION D3 NO.1)?

1. Condition of the health service venue 4. Medicine and vaccine supply 2. Attentiveness of the medical officers 5. Waiting time 3. Affordability of the health services 95. Others, ____________________________

4. In general, are you satisfied, somewhat satisfied, somewhat unsatisfied, or not satisfied with the health services in ___ (ANSWER SECTION D3 NO.1)?

1. Satisfied 3. Somewhat unsatisfied 6. NOT APPLICABLE 2. Somewhat satisfied 4. Unsatisfied 8. DO NOT KNOW

5. Do you expect the health services in _____ (ANSWER SECTION D3 NO.1) to be improved or remain the same as the present condition?

1. Improved 3. Deteriorated 2. The same

6. If the health services in ____ (ANSWER SECTION D3 NO.1) has been improved, would you willing to pay more?

1. Yes 3. No

D5. Criticismism, Complains and Suggestion Post

1. Have you ever delivered a criticism, complain and suggestion regarding health services in this district/city in the last 2 years?

1. Yes 3. No NO.5

2. How did you deliver it? A. DELIVERED DIRECTLY TO HEALTH FACILITY B. SUGGESTION BOX IN HEALTH FACILITY OR

GOVERNMENT OFFICES C. FORUM WITH THE VILLAGE/KELURAHAN OFFICIAL D. FORUM WITH THE SUBDISTRICT OFFICIAL E. FORUM WITH THE DISTRICT OFFICIAL

F. FORUM WITH PROVINCIAL OFFICIAL G. MASS MEDIA (RADIO, TV, NEWSPAPER,ETC) H. FORUM WITH NGO I. FORUM WITH COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS,

_________________________________________

3. Do you satisfied with the follow-up of the criticism, complain and suggestion?

1. Yes SECTION D6 3. No

6. NOT APPLICABLE SECTION D6

4. Why you do not satisfied? _____________________________________________________________________________________________________________

SECTION D6 5. Why have you never delivered any criticism, complain or

suggestion before? A. NO MEDIA SECTION D6 B. NO CRITICISM, COMPLAIN OR SUGGESTION C. AFRAID

D. USELESS (RELUCTANT, HAVING ASSUMPTION THAT THERE WILL BE NO RESPONSE)

E. ALREADY DELIVERED BY OTHERS V. OTHERS,

_________________________________________

6. As far as as you know, does the media to deliver criticism, complain and suggestion available?

1. Yes 3. No SECTION D6

7. What is the media you know to deliver criticism, complain A. DELIVERED DIRECTLY TO THE HEALTH FACILITY F. FORUM WITH PROVINCIAL OFFICIAL

Household

and suggestion? B. SUGGESTION BOX IN HEALTH FACILITY OR GOVERNMENT OFFICES

C. FORUM WITH VILLAGE/KELURAHAN OFFICIAL D. FORUM WITH SUBDISTRICT OFFICIAL E. FORUM WITH DISTRICT OFFICIAL

G. MASS MEDIA (RADIO, TV, NEWSPAPER, ETC H. FORUM WITH NGO I. FORUM WITH COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS,

_________________________________________

D6. Corruption and Bribery in Local Health Department (Dinas), Public Hospital and Puskesmas

1. Have you ever heard/informed any corruption case in local Health Dinas, public hospital and Puskesmas in this district in the last 2 years, such as:

- Misused of health fund - Corruption of medicine/health equipment by medical officers (e.g for private doctor or

Puskesmas midwife practice)

1. Yes, case _____________________________________________________________________ 3. No

2. Have you ever heard/informed any bribery case in local Health Dinas, public hospital and Puskesmas in this district in the last 2 years, such as:

- paid more money to get a faster/Improve health service

1. Yes, case _____________________________________________________________________ 3. No

Household

E. EDUCATION E1. Education Access and Cost for Household Member

INTERVIEWER REMARKS: IS THERE ANY OF THE HH MEMBER STILL STUDYING AT ELEMENTARY SCHOOL/JUNIOR HIGH SCHOOL/HIGH SCHOOL? (LOOK AT THE HH MEMBER ROSTER IN SECTION B PAGE 4 NUMBER 8)

1. YES 3. NO SECTION E2

1. HH member number

2. What is the school name? 3. What is the school status?

1. Public 2. Private

4. What is the mean of transportation that usually used to go to school?

A. On foot D. Car B. Bicycle E. Boat C. Motorcycle V. Others, ______

5. How long does it take to travel from home to school?

6. How much transportation cost do you need every day?

└─┴─┘ 1 2 A B C D E V ___________________ └─┴─┴─┘ minutes Rp. └─┴─┘.└─┴─┴─┘






How much [...] have been spent during the Semester I/Odd Semester on academic year (AY) 2005-2006? 7. HH member number

8. Did principal/school committee ever socialized/informed the school fee that will be burdened to the parents for the academic year 2005-2006?


9. Does this school receive operational aid fund or BOS?

1. Yes 3. No 6. NOT

APPLICABLE 8. DO NOT

KNOW

10. Registration fee/Initial fee/Re-registration fee (Rp.)

11. Tuition fee/BP3 fee/school committe Fee (Rp./month)

12. Text book and stationery cost (Rp.)

INTERVIEWER REMARKS:

APPLIED FOR TEXT BOOKS AND STATIONERIES BOUGHT FROM BOTH THE SCHOOL AND OUTSIDE SCHOOL.

INTERVIEWER REMARKS: ASK QUESTION NO. 13 IF THE ANSWER FOR NO.9 IS “YES”. 13. Was there any

deduction/waiver/refund of school fees in the AY 2005-2006 after the BOS program?

1. Yes 3. No 6. NOT APPLICABLE

└─┴─┘ 1 3 8 1 3 6 8 └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘.└─┴─┴─┘ 1 3 6

└─┴─┘ 1 3 8 1 3 6 8 └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘.└─┴─┴─┘ 1 3 6

└─┴─┘ 1 3 8 1 3 6 8 └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘.└─┴─┴─┘ 1 3 6

└─┴─┘ 1 3 8 1 3 6 8 └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘.└─┴─┴─┘ 1 3 6

Household

└─┴─┘ 1 3 8 1 3 6 8 └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘.└─┴─┴─┘ 1 3 6

└─┴─┘ 1 3 8 1 3 6 8 └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘.└─┴─┴─┘ 1 3 6

E2. Reason for Not Going to School

INTERVIEWER REMARKS: IS THERE ANY HH MEMBER WHO IS NOT IN ELEMENTARY/JUNIOR HIGH/HIGH SCHOOL, EVEN THOUGH THE PERSON SHOULD BE IN SCHOOL? (LOOK AT HH MEMBER ROSTER SECTION B PAGE 4 NUMBER 7 AND 8)

1. YES 3. NO SECTION E3

1. HH member number

2. How long [...] have you quit school? 3. What is the reason [...] for quitting school? A. HAS GRADUATED FROM ELEMENTARY/JUNIOR/HIGH SCHOOL C. WORKING B. CAN NOT AFFORD THE SCHOOL FEE V. OTHERS, ____________

└─┴─┘ └─┴─┘ year A B C V ______________________________________________________________________________________________

└─┴─┘ └─┴─┘ years A B C V ______________________________________________________________________________________________

└─┴─┘ └─┴─┘ year A B C V ______________________________________________________________________________________________

└─┴─┘ └─┴─┘ year A B C V ______________________________________________________________________________________________

E3. Assessment on Education Services

INTERVIEWER REMARKS: ASK THE SECTION E3 QUESTION EVEN THOUGH NO HH MEMBER IS IN ELEMENTARY/JUNIOR HIGH/HIGH SCHOOL.

1. What is the name of school that you most familiar with? INTERVIEWER REMARKS: THE SCHOOL WHICH THE RESPONDENT IS MOST FAMILIAR

WITH, DIRECTLY (FOR EXAMPLE THROUGH MEETINGS WITH THE PRINCIPAL/SCHOOL COMMITTEE) AND INDIRECTLY (FOR EXAMPLE THROUGH CHILDREN REPORT OR THE COMMUNITY REPORT).

a. School name: _________________________________________________________________ b. Location:

________________________________________________________________________

INTERVIEWER REMARKS: IF UNFAMILIAR WITH THE SCHOOL NAME THEN WRITE “Y” FOR THE SCHOOL NAME SECTION E4.

2. What is the status of the school? 1. Public 2. Private

We would like to ask for your opinion on the education services in _____ (THE EDUCATION FACILITY WHICH IS MOST FAMILIAR FOR THE RESPONDENT OR LOOK AT THE ANSWER FOR SECTION E3 NO.1)

3. According to you, in overall, is the current education services in ____ (ANSWER OF SECTION E3 NO.1) has been improved or deteriorated compared to 2 years ago?


4. According to you how is the current [...] in ___ (ANSWER OF SECTION E3 NO.1) compared to 2 years ago?

Household

a. School building and equipment condition 1. Improved 3. Deteriorated 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

b. Teachers’ attentiveness toward students 1. Improved 3. Deteriorated 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

c. School fee 1. More affordable 3. More unaffordable 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

d. Student academic achievements INTERVIEWER REMARKS: NUMBER OF STUDENTS GRADUATE, NUMBER OF

STUDENTS CONTINUING TO THE NEXT EDUCATION LEVEL, NUMBER OF AWARDS RECEIVED AS WELL AS PARTICIPATION TO COMPETITIONS.


e. Extracurricular activity INTERVIEWER REMARKS: STUDENT ACTIVITY OUTSIDE SCHOOL HOUR.


5. What is the most important thing to improve in _____ (ANSWER SECTION E3 NO.1)? 1. Condition of school building and equipment 4. Student academic achievements 2. Teacher’s attentiveness towards student 5. Extracurricular activities 3. Affordability of school fee 95. Others, ____________________________

6. In overall, are you satisfied, somewhat satisfied, somewhat unsatisfied or unsatisfied with the education services in ___ (ANSWER OF SECTION E3 NO.1)?


7. Do you wish for the education services in _____ (ANSWER OF SECTION E3 NO.1) to be improved or remain the same as the present condition?

1. Improved 3. DETERIORATED 2. The same

8. If the education services in _____ (ANSWER OF SECTION E3 NO.1) being improved, would you willing to pay more?

1. Yes 3. No

E4. Criticisms, Complaints and Suggestions Post

1. Have you ever delivered any criticism, complain and suggestion regarding education services in this district in the last 2 years?

1. Yes 3. No NO.5

2. How did you deliver it? A. DELIVERED DIRECTLY TO THE EDUCATION FACILITY B. SUGGESTION BOX IN THE EDUCATION FACILITY OF


F. FORUM WITH THE PROVINCIAL OFFICIAL G. MASS MEDIA (RADIO, TV, NEWSPAPER, ETC) H. FORUM WITH THE NGO I. FORUM WITH THE COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS,

_________________________________________

3. Do you satisfied with the follow-up of the criticism, complain 1. Yes SECTION E5 6. NOT APPLICABLE SECTION E5

Household

and suggestion? 3. No


SECTION E5 5. Why you have never delivered any criticism, complain or

suggestion before? A. NO MEDIA SECTION E5 B. NO CRITICISMISM, COMPLAINT OR SUGGESTION C. AFRAID


E. ALREADY DELIVERED BY OTHERS V. OTHERS,

_________________________________________

6. As far as you know, does the media to deliver criticism, complain and suggestion available?

1. Yes 3. No SECTION E5

7. What is the media you know to deliver criticism, complain and suggestion?

A. DELIVER DIRECTLY TO THE EDUCATION FACILITY B. SUGGESTION BOX IN EDUCATION FACILITY OR

GOVERNMENT OFFICES C. FORUM WITH VILLAGE/KELURAHAN OFFICIAL D. FORUM WITH SUBDISTRICT OFFICIAL E. FORUM WITH DISTRICT OFFICIAL

F. FORUM WITH THE PROVINCIAL OFFICIAL G. MASS MEDIA (RADIO, TV, NEWSPAPER, ETC) H. FORUM WITH NGO I. FORUM WITH COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS,

_________________________________________

E5. Corruption and Bribery in Local Education Dinas and Public School

1. Have you ever heard/informed any corruption case within the Education Dinas and public school (including public Islamic school/Madrasah) in this district in the last 2 years, such as:

- Misused of building rehabilitation fund - Misused of scholarship fund - Misused of teachers/school employees’ salary

1. Yes, case ______________________________________________________________________ 3. No

2. Have you ever heard/informed any bribery case in the Education Dinas and public school (including public Islamic school/Madrasah) in this district in the last 2 years, such as:

- Principal/teacher received commission from book publisher or distributor - Parents paid a sum of money to the principal/teacher to get their children pass the

admission of that school - Parents paid a sum of money to get their children graduate from school/pass the test

or to increase the score.

1. Yes, case ______________________________________________________________________ 3. No

F. ADMINISTRATION SERVICES IN VILLAGE/KELURAHAN

F1. Processing Identity Card (KTP)

Household

INTERVIEWER REMARKS: IF IN THE LAST 2 YEARS RESPONDENT OR OTHER HH MEMBER HAS BEEN PROCESSING KTP FOR MORE THAN ONCE; PLEASE REFER TO THE LATEST OCASSION.

1. In the last 2 years, did you or other HH member processing KTP? 1. Yes 3. No SECTION F2

2. Did you or other HH member receive any information about the KTP application/extention procedure (including the required supportive documents, cost and how long would it take to complete the process)?

1. Yes 3. No

3. How long did it take to get a KTP? └─┴─┴─┘ 1. Hours 2. Days 3. Months

4. How much was the total cost required to get a KTP (excluding transportation cost) 1. Rp. └─┴─┴─┘.└─┴─┴─┘ 8. DO NOT KNOW 3. For free

5. Dis this person or other HH member use a service of an intermediary? 1. Yes 3. No SECTION F2

6. What was the status of the intermediary? [Who was the intermediary?] 1. Insider 5. Others, ____________________________ 2. Professional agent/Service Bureau 8. DO NOT KNOW

7. Why did you use an intermediary? A. CHEAPER (FOR EXAMPLE OTHER COSTS, SUCH AS TRANSPORTATION COST, IS MORE EXPENSIVE THAN PAYING AN INTERMEDIARY)

B. TIME EFFICIENCY (FOR EXAMPLE PREFER TO USE THE TIME TO WORK INSTEAD OF PROCESSING A KTP)

C. DO NOT WISH TO EXPERIENCE THE PROCEDURE TO PROCESS KTP (FOR EXAMPLE RESPONDENTS DO NOT KNOW A KTP PROCESSING PROCEDURE, OR THINK THAT SUCH PROCEDURE IS TOO COMPLICATED OR UNCLEAR)

V. OTHERS,______________________________________________________________________

. Did intermediary fee already include in the cost (ANSWER NO.4) you or other HH member paid? 1. Yes 3. No F2. Assessment of the Overall Administration Services in this village/kelurahan

We would like to ask for your opinion on the administration services in this village/kelurahan.

1. According to you, in overall, is the current administration services in this village/kelurahan improved or deteriorated compared to 2 years ago?


2. According to you, how is the current [...] in this village/kelurahan compared to 2 years ago?

a. Courtesy of the village/kelurahan officials 1. Improved 3. Deteriorated 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

b. Requirement simplification 1. Improved 3. Deteriorated 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

c. Procedure simplification 1. Improved 3. Deteriorated 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

Household

d. Processing time 1. Shorter 3. Longer 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

e. Services cost 1. More affordable 3. More unaffordable 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

3. What is the most important aspect on administration service that needs to be improved in this village/kelurahan Office?

1. Courtesy of the employees in the Village/kelurahan office. 4. Processing time 2. Requirement simplification 5. Affordability of services cost 3. Procedure simplification 95. Others, ____________________

4. In overall, are you satisfied, somewhat satisfied, somewhat unsatisfied, or not satisfied with the adminisration services in this village/kelurahan office?


F3. Criticismism, Complaints and Suggestions Post

1. Have you ever delivered a criticism, complain and suggestion regarding administration services in this district in the last 2 years?

1. Yes 3. No NO.5

2. How did you deliver it? A. DELIVERED DIRECTLY TO THE VILLAGE OFFICE B. SUGGESTION BOX IN THE VILLAGE OFFICE OR OTHER


F. FORUM WITH THE PROVINCIAL OFFICIAL G. MASS MEDIA (RADIO, TV, NEWSPAPER, ETC) H. FORUM WITH THE NGO I. FORUM WITH THE COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS, _________________________________________


1. Yes SECTION F4 3. No

6. NOT APPLICABLE SECTION F4


SECTION F4 5. Why have you never delivered any criticism, complain or

suggestion before? A. NO MEDIA SECTION F4 B. NO CRITICISM, COMPLAINT OR SUGGESTION C. AFRAID


E. ALREADY DELIVERED BY OTHERS V. OTHER, _________________________________________


1. Yes 3. No SECTION F4

7. What is the media you know that functions as a mean to deliver criticism, complaint and suggestion?

A. DELIVER IT DIRECTLY TO THE VILLAGE/KELURAHAN OFFICE

B. SUGGESTION BOX IN THE VILLAGE/KELURAHAN OR

F. FORUM WITH THE PROVINCIAL OFFICIAL G. MASS MEDIA (RADIO, TV, NEWSPAPER, ETC) H. FORUM WITH THE NGO

Household

OTHER GOVERNMENT OFFICES C. FORUM WITH THE VILLAGE/KELURAHAN OFFICIAL D. FORUM WITH THE SUBDISTRICT OFFICIAL E. FORUM WITH THE DISTRICT/CITY OFFICIAL

I. FORUM WITH THE COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS, _________________________________________

F4. Corruption and Bribery in the Village/Kelurahan Office

1. Have you ever heard/informed any corruption case in the village/kelurahan office, in the last 2 years such as:

- Misuse of the village/kelurahan budget/financial/fund - Misuse of aid from the government/other parties, such as RASKIN, PKPS-BBM

1. Yes, case ______________________________________________________________ 3. No

2. Have you ever heard/informed any bribery case in the village/kelurahan Office in the last 2 years such as:

- Land dispute case in which the community paid a sum of money to the village head/lurah in order to get ownneship of the land

- Illegal levy during document registration or administration process

1. Yes, case ______________________________________________________________ 3. No

G. POLICE G1. Access 1. In the last 2 years, have you or other HH member ever used police services? 1. Yes 3. No NO.4

2. What was your or other HH member purpose in using police services? A. PROPOSING DOCUMENTS ADMINISTRATION (SKKB, SIM, STNK, PERMIT, ETC) B. REPORTING A CRIME OR ASKING FOR HELP A CRIME C. REPORTING DOMESTIC VIOLENCE D. REPORTING OTHER KIND DISPUTE OR ASKING FOR HELP TO SETTLE DISPUTE V. OTHERS, _____________________________________________________________________

3. Has this person or other HH member ever being asked/gave a sum of ‘money’ (graft money, “cigarette money”, etc) by the police to get a faster case investigation?

1. Yes 3. No

4. In the last 2 years, have you or other HH member ever seen police undertook on duty visit to your neigborhood?

1. Yes 3. No SECTION G2

5. What was the purpose of that visit? A. PATROL/SUPERVISE ENVIRONMENT SAFETY B. DELIVER A LAW SOCIALIZATION FOR THE PEOPLE IN THE VILLAGE/KELURAHAN (SUCH

AS DRUGS, TRAFFIC REGULATION, DRIVER LICENSE PROCEDURE, ETC) C. CASE PROCESSING OR A BURGLARY INVESTIGATION D. CASE PROCESSING OR INVESTIGATION OF A CONFLICT/DISPUTE V. OTHERS, _____________________________________________________________________

Household

Y. DO NOT KNOW G2. Driving License (SIM) Process INTERVIEWER REMARKS: IF IN THE LAST 2 YEARS RESPONDENT OR OTHER HH MEMBER HAS PROCESSED A SIM (DRIVER LICENSE) FOR MORE THAN 1 TIME, PLEAS REFER TO THE LATEST PROCESS.

1. In the last 2 years, have you or other HH member ever processed SIM until finished? 1. Yes, SIM type __________ 3. No SECTION G3

2. Have you other HH member received any information regarding the processing/extending procedure of SIM (including the supporting documents required, cost and time of processing)?

1. Yes 3. No

3. How long did it take to get a SIM? └─┴─┴─┘ 1. Hour 2. Day 3. Month

4. How much the total cost required to get a SIM (excluding transportation cost) 1. Rp. └─┴─┴─┘.└─┴─┴─┘ 8. DO NOT KNOW 3. Do not pay

5. Dis you or other HH member use a service of an intermediary? 1. Yes 3. No SECTION G3

6. What was the status of the intermediary? [Who was the intermediary?] 1. Insider 5. Others, ____________________________ 2. Professional agent/Services Bureau 8. DO NOT KNOW

7. Why did you use an intermediary? A. CHEAPER (FOR EXAMPLE OTHER COSTS, SUCH AS TRANSPORTATION COST, IS MORE EXPENSIVE THAN PAYING AN INTERMEDIARY)

B. TIME EFFICIENCY (FOR EXAMPLE PREFER TO USE THE TIME TO WORK INSTEAD OF ARRANGING A KTP)

C. DO NOT WISH TO EXPERIENCE THE PROCEDURE TO PROCESS SIM (FOR EXAMPLE RESPONDENTS DO NOT KNOW SIM PROCESSSING PROCEDURE, OR THINK THAT SUCH PROCEDURE IS TOO COMPLICATED OR UNCLEAR)

V. OTHERS,______________________________________________________________________

8. Did intermediary fee already include in the cost (ANSWER NO.4) you or other HH member paid? 1. Yes 3. No G3. Assessment of Police Services We would like you to do an assessment of the police services in this district. We are going to ask you to compare the current condition to the condition 2 years ago. INTERVIEWER REMARKS: DEFINITION OF POLICE IN THE DISTRICT IS THE POLICE WHOSE DUTY IS WITHIN THE SCOPE OF DISTRICT WHERE THE RESPONDENT LIVES. (NOT ONLY THE POLICE WORKING IN THE POLICE OFFICE IN DISTRICT (POLRES))

1. According to you, in overall, is the current police services in this district is improved or deteriorated compared to 2 years ago?

1. Improved 6. NOT APPLICABLE. NO. 3 2. THE SAME 8. DO NOT KNOW NO. 3 3. Deteriorated

2. According to you, how is the current [...] in this district compared to 2 years ago?

a. The police attitude in doing their duties 1. Improve 3. Deteriorate 8. DO NOT KNOW

Household

INTERVIEWER REMARKS: HELPFUL, FRIENDLY,ETC 2. THE SAME 6. NOT APPLICABLE

b. Services Cost 1. More affordable 3. More unaffordable 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

c. Law Enforcement INTERVIEWER REMARKS: REGULATION/LAW ENACTMENT IN SOLVING

CASES.

1. Improve 3. Deteriorate 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

d. Promptness in processing case INTERVIEWER REMARKS: THE POLICE’S RESPONSIVENESS IN PROCESSING

THE SUBMITTED REPORTS AND ABILITY IN CASE SOLVING.


e. Objectivity in processing case INTERVIEWER REMARKS: NEUTRAL AND FAIR.


3. What is the most important aspect of police services that needs to be improved in this district? 1. The police attitude in doing their duties 4. Promptness in processing case 2. Affordability of service cost 5. Objectivity in processing case 3. Law enforcement 95. Others, ____________________________

4. In In overall, you are you satisfied, somewhat satisfied, somewhat unsatisfied or unsatisfied with the police services in this district?


G4. The Criticism, Complaint, and Suggestion Post

1. Have you ever delivered a criticism, complain and suggestion regarding police services in this district in the last 2 years?

1. Yes 3. No NO.5

2. How did you deliver it? A. DELIVERED DIRECTLY TO THE POLICE OFFICE B. SUGGESTION BOX IN THE POLICE OFFICE OR OTHER




1. Yes SECTION G5 3. No

6. NOT APPLICABLE SECTION G5

4. Why you do not satisfied? _________________________________________________________________________________________________ SEKSI G5 5. Why you have never delivered any criticism, complain or

suggestion before? A. NO MEDIA SECTION G5 B. NO CRITICISMISM, COMPLAINTS OR SUGGESTIONS C. AFRAID


E. ALREADY DELIVERED BY OTHERS V. OTHER, _________________________________________

Household



7. What is the media you know that functions as a criticism, complaint and suggestion?

A. DELIVERED DIRECTLY TO THE POLICE OFFICE B. SUGGESTION BOX IN THE POLICE OFFICE OR OTHER



G5. Corruption and Bribery in Police Services

1. Have you ever heard/informed any corruption case done by police officer in this district in the last 2 years, such as:

- Misuse of police budget

1. Yes, case _____________________________________________________________________ 3. No

2. Have you ever heard/informed any bribery case done by police officer in this district in the last 2 years, such as:

- Illegal levies during solving of crime, drug cases, disputes - Illegal levies on the streets - Illegal levies during processing documents (SKKB, SIM, STNK, dsb.) - Owner of entertainment place/drugs/gambilng bookie/pirated goods paid a sum of

money to the police in order to have the business untouched by the police.

1. Yes, case _____________________________________________________________________ 3. No

H. SECURITY

1. At present, how is your or other HH member’s level of security over physical threat/violence in your neighborhood?

1. Safe 3. Unsafe 2. Somewhat safe 4. Very unsafe

2. How is the present level of security over physical threat/violence compared to 2 years ago? 1. Increased 3. Decreased 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

3. At present, how is your or other HH member’s security level on ownership of goods? 1. Safe 3. Unsafe 2. Somewhat safe 4. Very unsafe

4. How is the present security level of ownership of goods compared to 2 years ago? 1. Increased 3. Decreased 8. DO NOT KNOW 2. THE SAME 6. NOT APPLICABLE

Household

I. DISPUTES/CONFLICTS

We would like to ask you about disputes/conflicts that occured in this village/kelurahan in the last 2 years.

2. In general, who would usually takes part in the effort to resolve the dispute/conflict occured?

Type of Dispute/Conflict 1. Has any […] occured in this village/kelurahan in the last 2 years?


A. PARALEGAL B.

COMMUNITY/RELIGIOUS/CUSTOMS FIGURES

C. VILLAGE OFFICIAL D. NON-GOVERNMENTAL

ORGANIZATION (COUNSELOR) E. POLICE F. FAMILY MEMBER/FRIEND

G. LAWYER H. SUBDISTRICT OFFICER I. DISTRICT OFFICER J. DISTRICT ATTORNEY V. OTHERS, _______________ Y. DO NOT KNOW

3. According to you, what is the level of satisfaction of the parties in dispute/involved in a conflict, to that effort to resolve the dispute or conflict?

1. Very satisfied 2. Satisfied 3. Unsatisfied 4. Very unsatisfied 8. DO NOT KNOW

a. Land/building dispute/conflict among the people and/or between the government and the people

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

b. Dispute/conflict resulting from general crime (theft, homicide, etc)

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

c. Dispute/conflict resulting from misuse of power/authority

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

d. Dispute or conflict resulting from marriage/divorce/legacy

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

e. Dispute/conflict resulting from domestic violence

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

f. Dispute/conflict related with the Pilkades (Village Head Election)/Pilkada (Regional Head Election/Pemilu (General Election)

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

g. Ethnocommunal/Religious/Group conflicts/disputes

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

4. Have you involved with judicial institution in the last 2 years? 1. Yes 3. No

5. According to you, would the judicial institution able to solve case fairly? 1. Yes 3. No 8. DO NOT KNOW

6. In a dispute, do you know his/her legal rights? 1. Yes 3. No

Household

J. PKPS BBM, PUBLIC PARTICIPATION AND SOCIAL TRUST

J1. Compensation Program to Reduce Fuel Subsidy - Rural Infrastructure (PKPS BBM – IP)

1. Is there any PKPS BBM program in the rural infrastructure sector of this village/kelurahan? 1. Yes NO. 3 3. No 8. DO NOT KNOW

INTERVIEWER REMARKS: QUESTION NO.2 SHOULD BE ASKED TO RESPONDENT IF THE PERSON CHOOSES “NO” OR “DO NOT KNOW” ON QUESTION NO.1; ACCORDING TO DEPARTMENT OF PUBLIC WORK’S DATA, THE VILLAGE RECEIVED PKPS BBM-IP. 2. Based on the information we have; this village/kelurahan received PKPS BBM-IP program in

2005. Do you know the program activities?

1. Yes 3. No SECTION J2 6. NOT APPLICABLE SECTION J2 8. DO NOT KNOW SECTION J2

3. Has the village head/lurah ever announced/informed the PKPS BBM-IP to the community? 1. Yes 3. No NO. 5 8. DO NOT KNOW NO. 5

4. What was the media used? A. BROCHURE/BOARD/INFORMATION FLYER B. MEETING/COMMUNITY ACTIVITY/PLACE OF WORSHIP C. DOOR TO DOOR VISITS V. OTHERS, _____________________________________________________________________

5. Do you or other HH member work in the PKPS BBM-IP program? 1. Yes 3. No

6. What is the benefit of the program for the people in this village/kelurahan A. JOB AVAILABILITY B. INCREASE FAMILY INCOME C. RURAL INFRASTRUCTURE AVAILABILITY V. OTHERS, _____________________________________________________________________

Household

J2. Participation

The community program or activities INTERVIEWER REMARKS: APART FROM THE PKPS BBM-IP PROJECT

1. As far as you or other HH member knows, has there been any [...] during 2005 in this village/kelurahan?


2. Do you or other HH member usually attend the program/activity planning meeting?

1. Never NO. 4 2. Absent more than attend 3. Attend more than absent 4. Always attend 6. NOT APPLICABLE NO. 4 8. DO NOT KNOW NO. 4

3. During the meeting, how active do you or other HH member in giving ideas or suggestions?

1. Never 2. More silent than

active 3. More active than

silent 4. Always active 8. DO NOT KNOW

4. Have you or other HH member ever contributes in form of money/goods/services for program/activity in 2005?


a. Village/kelurahan infrastructure improvement program (such as road construction, maintenance, improvement)

1 3 8 1 ( NO. 4) 2 3 4 6 ( NO. 4) 8 ( NO. 4)

1 2 3 4 8 1 3 8

b. Health services (such as Posyandu/Integrated Health Post) 1 3 8 1 ( NO. 4) 2 3 4 6 ( NO. 4) 8 ( NO. 4)

1 2 3 4 8 1 3 8

c. Water supply (such as public pumps for MCK [bathing, washing, latrine], rain water reservoir or other sources to overcome drought during the dry season)

1 3 8 1 ( NO. 4) 2 3 4 6 ( NO. 4) 8 ( NO. 4)

1 2 3 4 8 1 3 8

5. Compared to 2 years ago, how is your or other HH member participation in the

program/activities in this village/kelurahan? 1. Improved 6. NOT APPLICABLE 2. Similar 8. DO NOT KNOW 3. Deteriorated

J3. Social Trust

1. In general, do you consider your neighbors (hamlet/RW/RT) are trustworthy INTERVIEWER REMARKS: ASSUME OR BELIEVE THAT A PERSON IS

HONEST/GOOD/DOES NOT SUSPICIOUS EACH OTHER/DOES NOT HARM EACH OTHER.

1. Everyone is trustworthy 4. No one is trustworthy 2. Most of them are trustworthy 8. DO NOT KNOW 3. A few of them are trustworthy

2. In general, do the villagers from neighboring Village/kelurahan are trustworthy? 1. Everyone is trustworthy 4. No one is trustworthy 2. Most of them are trustworthy 8. DO NOT KNOW 3. A few of them are trustworthy

3. In general, do the people of different religions are trustworthy? 1. Everyone is trustworthy 4. No one is trustworthy 2. Most of them are trustworthy 8. DO NOT KNOW 3. A few of them are trustworthy

Household

4. In general, do the people of different ethnic races is trustworthy? 1. Everyone is trustworthy 4. No one is trustworthy

2. Most of them are trustworthy 8. DO NOT KNOW 3. A few of them are trustworthy

K. POLITICS

K1. Knowledge regarding National/Local Officials

1. Do you know the name of the current (….)? INTERVIEWER REMARKS: CHECK THE ACCURACY OF THE ANSWER

a. Chairman of the State House of Representatives (DPR RI)

1. Yes, ___________________________ 3. No 1. TRUE 3. FALSE

b. Governor of this province 1. Yes, ___________________________ 3. No 1. TRUE 3. FALSE

c. Head of Local House of Representatives (DPRD) in this District

1. Yes, ___________________________ 3. No 1. TRUE 3. FALSE

d. District head/mayor (if not yet inaugurated, mention the name of the elected district head/mayor)

1. Yes, ___________________________ 3. No 1. TRUE 3. FALSE

e. Village head/lurah 1. Yes, ___________________________ 3. No 1. TRUE 3. FALSE

K2. Direct Election of Regional Head (Pilkada)

INTERVIEWER REMARKS: CHECK WHETHER THERE HAS BEEN ANY PILKADA IN THIS DISTRICT IN THE LAST 1 YEAR!

1. YES 3. NO SECTION K3

1. Did you participate in the district head/mayor election? 1. Yes NO. 3 3. No

2. Why you did not participate in the election?? 1. Did not meet the requirements (age < 17 tahun) 3. Uninterested to vote 2. Unregistered (the age has met the requirement) 5. Others, _____________________

NO.6

3. Were you aware of the background and program of the district head and mayor candidates before the Pilkada held?

1. Yes 3. No NO. 5

4. Where did you get the information of the background and programs of the district head/mayor candidates?

A. CAMPAIGNS OF CANDIDATES/SUCCESS TEAM B. LURAH/VILLAGE HEAD, SUBDISTRICT HEAD, ETC. C. COMMUNITY/RELIGIOUS FIGURES D. FRIENDS,NEIGHBOURS.AND/OR FAMILY E. MASS MEDIA (RADIO, TV, NEWSPAPER, ETC.)

Household

V. OTHERS, _____________________________________________________________________

5. Does the factor [...] affect you in selecting a candidate?

a. Ethnicity 1. Yes 3. No

b. Religion 1. Yes 3. No

c. Program/work agenda 1. Yes 3. No

d. Performance/achievement in the past 1. Yes 3. No

6. In overall, do you satisfied, somewhat satisfied, somewhat unsatisfied, or unsatisfied with the Pilkada process?

1. Satisfied 2. Somewhat Unsatisfied 3. Unsatisfied 8. DO NOT KNOW SECTION K3

7. Why?

K3. Village/kelurahan Activities

1. During the last one year, have you received any information regarding:

a. Budget implementation of this village/kelurahan? 1. Yes 3. No

b. Development plan of this village/kelurahan? 1. Yes 3. No

2. Are you aware of the existence of the village legislature/assembly (BPD) or Board of Kelurahan (DK) or other similar institutions in this village/kelurahan?

1. Yes 3. No SECTION K4

3. As far as you know, have the people in this village/kelurahan brought any problem/complain to the members of BPD/DK in the last 1 year?

1. Yes 3. No SECTION K4 8. DO NOT KNOW SECTION K4

4. According to you, has the BPD/DK showed any effort to follow up the issue/complain? 1. Yes 3. No 8. DO NOT KNOW

K4. Access to Information

1. Do you follow the progress of the situation in this district/village? 1. Yes 3. No NO. 3

2 Where do you get the information from? A. LURAH/VILLAGE HEAD, HEAD OF HAMLET, ETC B. COMMUNITY/RELIGIOUS FIGURES C. FRIENDS,NEIGHBOURS,AND/OR FAMILY D. MASS MEDIA(RADIO, TV,NEWSPAPERS) V. OTHERS, __________________________

3. Do you follow the progress of the national situation? 1. Yes 3. No NO. 5

4. Where do you get the information? A. LURAH/VILLAGE HEAD, HEAD OF HAMLET, ETC B. COMMUNITY/RELIGIOUS FIGURES C. FRIENDS,NEIGHBOURS,AND/OR FAMILY

Household

D. MASS MEDIA(RADIO, TV,NEWSPAPERS) V. OTHERS, __________________________

5. During the last week, have you [...]?

a. listened to the radio 1. Yes 3. No

b. watched television 1. Yes 3. No

c. read national newspapers 1. Yes 3. No

d. read local newspapers 1. Yes 3. No

e. browsed/used the internet 1. Yes 3. No L. HOUSEHOLD ASSETS

1. Residence ownership status 1. Private ownership 4. Rent free 6. Belong to parents/children/other relative 2. Lease 5. Office housing 95. Others, ___________________________________ 3. Rent

2. Does this household have […]?

a. House/other buildings besides this house 1. Yes 3. No

b1. Land (used for agriculture or non-farm business or other land) 1. Yes 3. No NO. c1

b2. Tota Area of b1 └─┴─┴─┘.└─┴─┴─┘ m2 c1. Land which is accessible by the household although it does not belong to the

household 1. Yes 3. No NO.d

c2. Total Area of c1 └─┴─┴─┘.└─┴─┴─┘ m2 d. Large livestock 1. Yes 3. No

e. Small livestock/poultry/fishpond 1. Yes 3. No

f. TV (Color/Black and White) 1. Yes 3. No

g. Radio/tape recorder 1. Yes 3. No

h. Refrigerator 1. Yes 3. No

i. Water pump 1. Yes 3. No

j. Car 1. Yes 3. No

k. Boat 1. Yes 3. No

l. Motorcycle 1. Yes 3. No

Household

m. Bicycle 1. Yes 3. No

n. House telephone/handphone 1. Yes 3. No

o. Jewelries (gold, diamonds, etc.) 1. Yes 3. No

M. HOUSEHOLD INCOME AND SPENDING At the beginning of the interview, you have mentioned that the household member named _____, _____, _____ have been working/owned a job in the last 1 year (look at the Household Member Roster). We would like to ask the type of occupation and the income received from the occupation.

M1. Income from Own-agriculture Occupation

1. During the last one year, have you or other HH member owned an independent agriculture occupation?

INTERVIEWER REMARKS: THE AGRICULTURE SECTOR INCLUDING FARM, CULTIVATED FIELD, SMALL SCALE ESTATE, SMALL SCALE LIVESTOCK FARM, AND SMALL SCALE POND/FISHPOND

1. Yes 3. No SECTION M2

2. Plant/comodities 3. How many harvests in the last one year? 4. How much is the average income from

each harvest or each production? 5. How much is the total income in the last

one year? (NO.3 x NO. 4)

a.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

b.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

c.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

d.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

e.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

6. Total income from own-agriculture work Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Household

M2. Income from Own-Non-agriculture Occupation

1. During the last 1 year, have you or other HH member owned an own-non-agriculture occupation (entrepreneurship)?


2. HH member number

3. Main occupation in the last one year

4. Status of main occupation in the last one year

5. Average monthly income (from all income-generating occupation)

6. How many months of effective work in the last one year?

7. Annual income (from all income-generating occupation)

[NO.5 x NO.6]

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

8. Total income from own-non-agriculture work Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

INTERVIEWER REMARKS: SELECTION OF OWN-NON-AGRICULTURE OCCUPATION

3. Occupation field 4. Occupation Status

1. Mining and Quarrying 6. Transportation and Communications 2. Manufacturing 7. Finance 3. Electricity, gas and water 8. Services 4. Construction 95. Others, ___________________ 5. Trade

1. Self-employed business (without help from permanent/temporary/paid/unpaid labor) 2. Occupation helped by temporary labor/unpaid labor 3. Occupation helped by permanent/paid labor

Household

M3. Income from Salary/Wage

1. During the last 1year, have you or other HH member received salary/wage from working in a company or for other people?


2. HH

member number

3. Main occupation in the last 1 year

4. Status of the main occupation in the last 1 year

5. Average monthly income (from all occupations that generate salary/wage)

6. How many months of effective work in the last one year?

7. Annual income (from all occupations that generate salary/wage)

[NO.5 x NO.6]

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

8. Total income from salary/wage Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

INTERVIEWER REMARKS: CHOICES OF ANSWERS FOR INCOME FROM SALARY/WAGE

3. Main Occupation 4. Status of main occupation

1. Agriculture 6. Trade 2. Mining and Quarrying 7. Transportation and Communications 3. Manufacture 8. Finance 4. Electricity, gas and water 9. Services 5. Construction 95. Others, ____________________________

1. Civil servant 2. Private employee 3. Farm freelance workers 4. Non-farm freelance workers 5. Others, _______________________________________________________________________

Household

M4. Non occupational income

1. During the last one year, have you or other HH member received non occupational income, such as pension, grant, etc?


2. Income from […] in the last one year

a. Pension Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

b. Transfer/grant Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

c. Rent Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

d. Interest Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

3. Total income in the last one year INTERVIEWER REMARKS: DO THIS CALCULATION TOGETHER WITH RESPONDENT TO

ENSURE ACCURACY OF THE RESPONDENT’S ANSWER.

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘ [NO. 2a + 2b + 2c + 2d]

M5. Household SPENDING

1. Average monthly spending for food consumption

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

2. Average monthly spending for non food consumption (for example: school, water, electricity, transportation, health, social activity, house rent)

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

N. HOUSEHOLD ECONOMICS CONDITION

1. In general, how is the economic condition of this household compared to 2 years ago? 1. Improve 3. Deteriorate 2. The same 8. DO NOT KNOW

2. Why?

INTERVIEWER REMARKS: NO.3 IS THE ENUMERATOR PERSONAL ASSESSMENT/OPINION. DO NOT ASK THIS QUESTION TO THE RESPONDENT! 3. BASED ON THE LOCAL STANDARD OF WELFARE, THIS HOUSEHOLD WELFARE CAN BE

CATEGORIZED AS:

1. VERY WEALTHY 4. POOR 2. WEALTHY 5. VERY POOR 3. MIDDLE CLASS

O. INFORMATION FOR REVISIT

Household

Name 1 : ________________________________________________________________

Address 1 : ________________________________________________________________

Telephone 1 : └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘

1. We might visit your household again someday. If on our next visit your household is no longer located here anymore, please inform us contact detail of the person whom we should contact to get your new address?

Name 2 : ________________________________________________________________

Address 2 : ________________________________________________________________

Telephone 2 : └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘

BHS. LANGUAGE USED AND INFORMATION OF THE MAIN RESPONDENT

1. WHAT IS THE MOST FREQUENTLY USED LANGUAGE DURING INTERVIEW? 1. JAVA 7. MADURA 13. NIAS 19. LAMPUNG 2. SUNDA 8. SASAK 14. PALEMBANG 20. DAYAK 3. BALI 9. MINANG 15. SUMBAWA 21. INDONESIA 4. BATAK 10. BANJAR 16. TORAJA 95. OTHERS,________________ 5. BUGIS 11. BIMA 17. LAHAT 6. CHINESE 12. MAKASAR 18. BETAWI

2. WAS THERE ANY OTHER LANGUAGES USED? 1. AVAILABLE └─┴─┘ (SIMILAR PREFERENCE CODE TO NUMBER 1) 3. UNAVAILABLE

3. NUMBER THE MAIN RESPONDENTS IN ORDER (LOOK AT SECTION B HOUSEHOLD MEMBER ROSTER)

INTERVIEWER REMARKS: THE MAIN RESPONDENT IS THE MEMBER OF HOUSEHOLD WHO ANSWERS MOST OF THE QUESTIONS DURING THE INTERVIEW.

└─┴─┘

4. WHICH QUESTIONS WERE CONSIDERED DIFFICULT, EMBARASSING, OR CONFUSING

FOR RESPONDENT TO ANSWER? (WRITE THE SECTION AND THE NUMBER OF THE QUESTIONS)

5. ACCORDING TO THE INTERVIEWER, HOW WAS THE RESPONDENT’S HONESTY IN ANSWERING THE QUESTIONS?

Household

CP. INTERVIEWER NOTES

SECTION NO INTERVIEWER NOTES

CONFIDENTIAL


V I L L A G E H E A D / L U R A H

Village head/Lurah ID └─┴─┘└─┴─┘ 12 0└─┘ A. LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/Kelurahan *) Code └─┴─┴─┘ 5. Hamlet/_____________________________________ *) 6. Address └─┴─┴─┴─┴─┘ 7. Postal Code └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 8. Telephone *) Select one B. VILLAGE HEAD/LURAH IDENTITY AND GENERAL INFORMATION B1. Village Head/Lurah Identity INTERVIEWER REMARKS: QUESTIONS IN SECTION B1 ARE ONLY FOR THE VILLAGE HEAD/LURAH AND SHOULD NOT BE ASKED TO HIS/HER REPRESENTATIVE.

IS THE RESPONDENT THE VILLAGE HEAD/LURAH? 1. YES 3. NO SECTION B2

1. What is your complete name? 2. Since when have you become the head of this village/lurah? Month └─┴─┘ Year └─┴─┴─┴─┘ 3. What is your employment status? 1. Civil Servant (PNS) 2. Non civil Servant No.5

4. What is your employment rank? └─┴─┴─┘/└─┘ 5. Gender 1. Male 3. Female

Village Head/Lurah

6. What is your age at the moment? └─┴─┘ Years 7. What was the highest level of education you have completed? 1. Elementary School/Islamic Elementary (MI) 5. Diploma III

2. Junior High School/ Islamic Junior (MTs) 6. Diploma IV/S1-Bachelor 3. Senior High School/SMK/Islamic High (MA) 7. Post Graduate (S2/S3) 4. Diploma I/II 95. Others, ____________________________

8. Do you have other income generating occupation in the last 1 year? 1. Yes 3. No NO. 9 9. In what field/sector does this other occupation belong to? INTERVIEWER REMARKS: IF THE RESPONDENT WORKS IN SEVERAL

FIELDS/SECTORS, PLEASE ASK WHICH FIELD/SECTOR IN WHICH HE/HER ALLOCATED HIS/HER TIME THE MOST (IN HOURS/WEEKS) DURING THE LAST 1 YEAR

1. Agriculture 6. Trade 2. Mining and Quarrying 7. Transportation and Communications 3. Manufacture 8. Finance 4. Electricity, gas and water 9. Service 5. Construction 95. Others, ____________________________

10. What is your employment status in that other occupation? 1. Self employed 5. Private Employee 2. Business with temporary labor/unpaid labor 6. Farm freelance workers 3. Business with permanent labor/paid 7. Non-farm freelance workers 4. Civil Servant 95. Others, ___________________________

11. What is the percentage of your income as village head/lurah compared to the total income from your total work last month? └─┴─┴─┘ percent

INTERVIEWER REMARKS: QUESTIONS NUMBER 12 AND 13 SHOULD ONLY BE ASKED TO THE VILLAGE HEAD AND NOT TO LURAH

12. How long is the current governance period for village head? └─┴─┘ years 13. When is the next election for village head? 1. Month └─┴─┘ Year └─┴─┴─┴─┘ 8. DO NOT KNOW 14. How many hours, in average, in a week, do you work for issues related to this village? └─┴─┴─┘ hours 15. In case of emergency, can the villagers contact the village head/lurah at any time? 1. Yes 3. No

B2. Respondent Identity (If Village Head/Lurah absent/Unavailable) INTERVIEWER REMARKS: QUESTIONS IN SECTION B2 ARE ONLY FOR THE RESPONDENT THAT REPRESENTING THE VILLAGE HEAD/LURAH IS THE RESPONDENT THE VILLAGE HEAD/LURAH? 1. YES SECTION C 3. NO 1. What is your complete name? 2. What is your position in this village/kelurahan? 1. Village secretary/Kelurahan secretary

2. Head of Government Affairs

Village Head/Lurah

5. Others, _______________________________________________________________________

3. Since when did you become _____ (SEE ANSWER NO. 2) here? Month └─┴─┘ Year └─┴─┴─┴─┘ 4. What is your employment status? 1. Civil Servant (PNS) 2. Non civil Servant No.6


7. What is your age at the moment? └─┴─┘ tahun 8. What is the highest level of education you have completed? 1. Elementary School/Islamic Elementary (MI) 5. Diploma III

2. Junior High School/Islamic Junior High (MTs) 6. Diploma IV/S1-Bachelor 3. Senior High School/SMK/ Islamic High (MA) 7. Post Graduate (S2/S3) 4. Diploma I/II 95. Others, ____________________________

C. ASSESSMENET OF THE PUBLIC SERVICES (OTHER THAN HEALTHCARE AND EDUCATION SERVICES) PROVIDED BY THE DISTRICT GOVERNMENT

We would like to ask you to do an assessment to the public services (other than healthcare and education services) provided by the district government for the villagers of this village/kelurahan.

1. Is the current (.......) service in this district sufficient?

a. Clean water 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

b. Sanitation/sewerage 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

c. Road 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

d. Waste management 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

e. drainage management/flood mitigation 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

f. Irrigation system (for agriculture) 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

g. Public transportation 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

h. Street and public area lighting 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

i. Environment management (forests, mining, energy) 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

j. Licensing 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

2. From several public services mentioned before, according to you, which public services are (......)?

Respondent can mention other public services other than the above mentioned one.

1. Clean water 2. Sanitation/sewerage 3. Road 4. Waste management 5. Drainage management/flood mitigation 6. Irrigation system (for agriculture)

7. Public transportation 8. Street and public area lightening 9. Environment management (forests, mining,

energy) 10. Licensing 95. Others

Village Head/Lurah

a. Most sufficient 1 2 3 4 5 6 7 8 9 10 95,_________________________________________________

b. Most insufficient 1 2 3 4 5 6 7 8 9 10 95,_________________________________________________

D. PROCESSING IDENTITY CARD (KTP)

1. How long is the official time to process KTP? └─┴─┘ days 2. How much is the official cost to process KTP? Rp └─┴─┴─┘.└─┴─┴─┘

3. Is there any particular policy that regulates KTP process in this village/kelurahan? 1. Yes 3. No No.5

4. Who decided the policy? 1. VILLAGE HEAD/LURAH DECREE 3. CONSENSUS 2. VILLAGE REGULATION 5. OTHERS, __________________________

5. In the last 2 years, have you or other village/kelurahan officer held any socialization/counseling for the villagers, regarding the procedure to process KTP?

1. Yes, by using/through __________________________________________________________ 3. No, because

___________________________________________________________________

E. POOR FAMILIES (GAKIN)

1. What is the percentage of total GAKIN/Poor Family from the total household in this village/kelurahan? (estimated)

└─┴─┘percent

2. In 2005, was there any special government program for GAKIN/Poor Family in this village/kelurahan?

1. Yes, a. Program ________________________________________________________________ b. Program ________________________________________________________________ c. Program ________________________________________________________________ 3. No 8. DO NOT KNOW

3. In year 2005, was there any villager of this village/kelurahan that processing statement of poor (SKTM) for medical care, education, or other purpose?

1. Yes 3. No

4. In the last two years, have you ever heard/informed about villager who got discriminated/differentiated on health or education service because he/she was poor?


5. Mention the case of service discrimination/differentiated on the health and education sectors: a. Health Case, _______________________________________________________________ b. Education Case, _______________________________________________________________

Village Head/Lurah

F. COMPENSATION PROGRAM TO REDUCE FUEL SUBSIDY (PKPS BBM) F1. PKPS BBM – Rural Infrastructure (IP) Improvement

1. Does this village/kelurahan receive PKPS BBM-IP? 1. Yes 3. No SECTION F2

2. What project has been selected to be financed by the PKPS BBM-IP? A. RURAL ROADS F. SIMPLE DAM B. BRIDGES G. RURAL IRRIGATION C. BOAT MOORINGS H. POTABLE WATER SUPPLY D. EMBUNG V. OTHERS, __________________________ E. SURFACE WATER

3. Does the project carried out in the hamlet/equivalent of ____ (MENTION THE NAME OF THE HAMLET/EQUIVALENT 1 IN WHICH THE SURVEY LOCATION)?

1. Yes 3. No

4. Does the project carried out in the hamlet/equivalent of ____ (MENTION THE NAME OF THE HAMLET/EQUIVALENT 2 IN WHICH THE SURVEY LOCATION)?

1. Yes 3. No

5. When was the first grant disbursement for the project? Month └─┴─┘ Year └─┴─┴─┴─┘ 6. Is the project still in progress at the moment? 1. Yes 3. No

7. How did the project selected/authorized? 1. THROUGH VILLAGE/KELURAHAN MEETING 4. SELECTED BY THE VILLAGE/ KELURAHAN HEAD 2. THROUGH CLOSED MEETING BETWEEN 5. SELECTED BY THE SUBDISTRICT HEAD THE VILLAGE/KELURAHAN AND HEAD OF 6. SELECTED BY THE PUBLIC WORKS UNIT HAMLET/EQUIVALENT 3. THROUGH CLOSED MEETING AMONG 95. OTHERS, __________________________ HEAD OF HAMLET/EQUIVALENT 98. DO NOT KNOW

8. How much was the total budget for all programs in this village/kelurahan Rp. └─┴─┴─┘. └─┴─┴─┘.└─┴─┴─┘ 9. Who execute the project? 1. VILLAGE/KELURAHAN APPARATUS

2. CONTRACTOR FROM THIS VILLAGE/KELURAHAN 3. CONTRACTOR FROM OTHER VILLAGE/KELURAHAN 5. OTHERS, _____________________________________________________________________ 8. DO NOT KNOW

10. Was there any villager of this village/kelurahan working in the project? 1. Yes 3. No

11. How many villagers were working in the project? (estimated) └─┴─┴─┘ persons 12. What were the difficulties/obstacles/constraints faced during the implementation of the PKPS

BBM-IP? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

13. What is your suggestion to improve the PKPS BBM-IP? 1. ______________________________________________________________________________

Village Head/Lurah

2. ______________________________________________________________________________

F2. PKPS BBM – Unconditional Cash Transfer (SLT)

1. Does any of the villagers in this hamlet/equivalent receive PKPS BBM-SLT? 1. Yes 3. No SECTION F3

2. Have you ever attended a meeting/socialization about PKPS BBM-SLT? 1. Yes 3. No

3. Has the village/kelurahan government informed the villagers about the PKPS BBM-SLT prior to the initial data collection?

1. Yes 3. No NO.5

4. What device/media was used? A. BROCHURES/BOARDS, FLYER B. MEETINGS/GATHERINGS/RESIDENT ACTIVITIES/ACTIVITIES IN PLACES OF WORSHIP C. DOOR TO DOOR VISIT V. OTHERS, ____________________________________________________________________

5. Who did the data collection on poor families whom become the candidate to receive PKPS BBM-SLT?

A. VILLAGE/KELURAHAN APPARATUS E. BPS OFFICER/DATA COLLECTOR B. PKK/POSYANDU CADRE /BPS PARTNER/PARTNER C. PUSKESMAS OFFICER/MIDWIFE/PLKB ASSISTANT D. COMMUNITY LEADER V. OTHERS, ________________________

6. Did the village head/lurah play any role in the selection/appointment of the data officers? 1. Yes 3. No

7. Can the criteria set by the government to select the households as the candidate of PKPS BBM-SLT receiver, applied completely to this village/kelurahan?

1. Yes 3. No, because ________________________________________________________________ 6. NOT APPLICABLE NO.9 8. DO NOT KNOW

8. Do you consider the criteria set by the government already accurate? 1. Yes 3. No, because ________________________________________________________________

9. Was there any difference between the list of proposal and the list of recipients during the first phase of PKPS BBM-SLT for the period October-December 2005?


10. Has there been any sequel data collection after the first phase period of October-December 2005?


11. Who distributes the fuel Compensation/UCT cards? A. VILLAGE/KELURAHAN APPARATUS E. BPS OFFICER/DATA COLLECTOR B. PKK/POSYANDU CADRE /BPS PARTNER/PARTNER C. PUSKESMAS OFFICER/MIDWIFE/PLKB ASSISTANT D. COMMUNITY LEADER V. OTHERS, ________________________

12. How did they distribute the cards? 1. DELIVERED TO PEOPLE’S HOUSE 2. OBTAINED AT ____ (SEE ANSWER NO.11) 3. AT THE VILLAGE MEETING 5. OTHERS, ____________________________________________________________________

Village Head/Lurah

13. Before the disbursement of the PKPS BBM-SLT funds, have there been any notifications/announcements from the village/kelurahan government to the villagers about the venue, time and requirements for collecting of the money?

1. Yes 3. No NO.15

14. What device/media was used? A. BROCHURES/BOARDS, FLYER B. MEETINGS/GATHERINGS/FESTIVES/ACTIVITIES IN PLACES OF WORSHIP C. DOOR TO DOOR VISIT V. OTHERS, ____________________________________________________________________

15. What were the difficulties/obstacles/constraints faced during the implementation of the PKPS BBM-SLT?

1. _____________________________________________________________________________ 2. _____________________________________________________________________________

16. What is your suggestion to improve the PKPS BBM-SLT? 1. _____________________________________________________________________________ 2. _____________________________________________________________________________

F3. PKPS BBM – Health Sector (BK)

1. Does any of the villagers in this hamlet/equivalent receive PKPS BBM-BK or Health Insurance for the Poor Program (JPKMM)?


2. Was there any data collection process for the family whom become the candidate to receive PKPS BBM-BK?

1. Yes 3. No NO.5

3. Who did the data collection? A. DISTRICT/CITY HEALTH OFFICIAL D. VILLAGE/KELURAHAN APPARATUS B. BKKBN (Family Planning) Official V. OTHERS, _________________________ C. PUSKESMAS Official

4. Was there any difficulty in the data collection and selection process of the people who is eligible to participate in this PKPS BBM-BK/JPKMM?

1. Yes 3. No, because _________________________________________________________________ 8. DO NOT KNOW

5. Have all villagers who have been declared to be eligible to participate in the PKPS BBM-BK/JPKMM received their JKPMM cards?

1. Yes 3. No

F4. Complaint/Suggestion Related to PKPS BBM INTERVIEWER REMARKS: QUESTIONS NO.1-3 ARE RELATED TO PKPS BBM – IP, SLT AND BK

1. Are there any.[...] linked to the PKPS BBM for Rural Infrastructure, UCT or Health Sector/JPKMM in this hamlet/equivalent?

a. Complaint/protest from villagers 1. Yes 3. No

b. Disturbances/fights 1. Yes 3. No

c. Rallies of protests 1. Yes 3. No

d. Villagers who deliver information regarding the program implementation 1. Yes 3. No

Village Head/Lurah

INTERVIEWER REMARKS: IF NUMBERS 1 a, b, c AND d = NO SECTION G 2. Has the village/kelurahan government ever delivered complaint/protest/suggestion advice from

the people, to the officer/institutions in charge for the implementation of PKPS BBM in this village/kelurahan?

1. Yes, to___________________________________________________________________ 3. No SECTION G

3. Was the response from the officer/institutions sufficient? 1. Yes 3. No

G. PROGRAMS/ACTIVITIES AND COMMUNITY PARTICIPATION

Programs/Activities

INTERVIEWER REMARKS: OTHER THAN PKPS BBM–IP PROJECTS

1. During 2005, has there been any […] in this village/kelurahan?

2. Who financed the activity? A. VILLAGERS B. VILLAGE/KELURAHAN GOVERNMENT FUNDS C. DISTRICT/CITY GOVERNMENT FUNDS D. PROVINCIAL GOVERNMENT FUNDS E. CENTRAL GOVERNMENT FUNDS F. DONORS/NON GOVERNMENT ORGANIZATIONS V. OTHERS, _________________ Y. DO NOT KNOW

a. Village/ kelurahan infrastructure improvement Programs (such as construction, maintenance, improvement of roads, sports facilities, education facilities, etc.)

1. Yes, namely program ________________________________ __________________________________________________ 3. No

A B C D E F V ___________________________________________________ Y

b. Health services (such as fogging to mitigate dengue fever, baby weighing stations, integrated health post/Posyandu, etc.)

1. Yes, program_______________________________ __________________________________________________ 3. No

A B C D E F V ___________________________________________________ Y

c. Clean water supply and sanitation (such as public pumps for MCK (Bathing, Washing, Latrine) needs, rain water collection or other sources to overcome the drought during the dry season, etc).

1. Yes, program_______________________________ __________________________________________________ 3. No

A B C D E F V ___________________________________________________ Y

3. According to you, is it difficult or easy to organize meeting with villagers to discuss development activities in this village/kelurahan?

1. Easy 2. Normal 3. Difficult

4. What kind of support/participation do the villagers provide for the development of this village/kelurahan?

A. NO SUPPORT NO.6 B. MANPOWER (VOLUNTARY LABOR/GOTONG ROYONG) C. PROVIDE OPINIONS/SUGGESTIONS D. PAY SUBSCRIPTIONS FOR ACTIVITIES/DEVELOPMENT

Village Head/Lurah

V. OTHERS, _____________________________________________________________________

5. Do you, consider that the support/participation from villagers sufficient? 1. Sufficient 3. Insufficient 8. DO NOT KNOW

6. According to you, has the support/participation of villagers for the development of this village/kelurahan improved or deteriorated during the last 2 years?

1. Improved 3. Deteriorated 2. The Same 8. DO NOT KNOW

H. RELATIONSHIP OF VILLAGE HEAD/LURAH WITH PUBLIC SERVICE PROVIDER

1. During 2005, has this village/kelurahan ever received meeting invitation or visit from leader/staff (…..) in term of duties?

2. During 2005 has this village/kelurahan government ever sent meeting invitation or visit the leader/staff (…..) in term of duties?

3. INTERVIEWER REMARKS: IF NO. 1 = YES OR NO.2 = YES

What were the topics discussed?

a. Puskesmas (Community Health Center) 1. Yes 3. No 1. Yes 3. No a. ______________________________________ b. ______________________________________

b. Public school (Primary, Junior High and Senior High Schools)

1. Yes 3. No 1. Yes 3. No a. ______________________________________ b. ______________________________________

c. Police 1. Yes 3. No 1. Yes 3. No a. ______________________________________ b. ______________________________________

3. Has this village/kelurahan government

received criticism, complaints and suggestions from villagers related to services from (....)?

4. What has this village/kelurahan government done to the criticism, complaints and suggestions (....)?

A. FORMALLY SUBMITTED IT B. INFORMALLY SUBMITTED IT C. SUGGESTED THE VILLAGERS TO

DELIVER IT DIRECTLY D. FOLLOWED UP E. IGNORED V. OTHERS,

___________________________

5. As far as you know, has (...) responded to the criticism, complaints and suggestions from villagers?

a. Puskesmas (Community Health Center) 1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

b. Public schools (Primary, Junior High, Senior High schools)

1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

c. Police 1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

d. Village/kelurahan government 1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

Village Head/Lurah

I. CORRUPTION CASES RELATED TO PUBLIC SERVICES

1. Have you ever heard/informed any case of corruption/misuse of authority in this district/city in the last 2 years?

a. Public hospitals/Puskesmas

b. Public schools (Primary, Junior High, Senior High)

c. Police

d. Village/kelurahan government J. TRUST AMONG RESIDENTS

1. According to you, do (...) trustworthy or untrustworthy?

a. Villagers of this village/kelurahan 1. Trustworthy 3. Untrustworthy

b. Villagers of neighboring villages/kelurahan 1. Trustworthy 3. Untrustworthy

c. Migrants from other regions/ethnic groups 1. Trustworthy 3. Untrustworthy

d. People of different religions 1. Trustworthy 3. Untrustworthy

K. DISPUTES/CONFLICTS We would like to ask about dispute/conflict that occured in this village/kelurahan in the last 2 years.

2. In general, who would usually takes part in the effort to resolve the dispute/conflict occured?

Type of dispute/conflict 1. Has any […] occured in this village/kelurahan in the last 2 years?


A. PARALEGAL B. COMMUNITY/RELIGIOUS/

CUSTOMS FIGURES C. VILLAGE OFFICERS D. NONGOVERNMENT

ORGANIZATION (FACILITATOR)

E. POLICE F. FAMILY MEMBER/FRIEND


3. According to you, what is the level of satisfaction of the parties in dispute/involved in a conflict, to that efforts to resolve the dispute or conflict

1. Very satisfied 2. Satisfied 3. Unsatisfied 4. Very unsatisfied 8. DO NOT KNOW


1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

b. Disputes/conflicts as a result of general 1 3 8 A B C D E F G H I J 1 2 3 4 8

Village Head/Lurah

criminal acts (theft, homicide, etc.) V __________________________________________________ Y

c. Disputes/conflicts as a result of misuse of power/authority

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

d. Disputes/conflicts as a result of marriage/divorce/legacy

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

e. Disputes/conflicts as a result from domestic violence

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

f. Disputes/conflicts related with Pilkades (Village Head Election)/Pilkada (Regional Head Election/Pemilu (General Election)

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8


1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8


5. According to you, is does the judicial institution able to rulesolve an issuecase in a fair manner? 1. Yes 3. No 8. DO NOT KNOW

6. In a dispute, do you know your legal rights? 1. Yes 3. No L. SOURCE OF INFORMATION

1. Does this hamlet/equivalent within the reach of (...)?

a. Radio broadcast 1. Yes 3. No

b. National television broadcast 1. Yes 3. No

c. Regional/local television broadcast 1. Yes 3. No 6. NOT APPLICABLE

d. National newspaper 1. Yes 3. No

e. Regional/local newspaper 1. Yes 3. No 6. NOT APPLICABLE

f. Internet access 1. Yes 3. No 8. DO NOT KNOW

2. What sources of information that you most frequently used to find out about conditions and policy progress at district/city level?

1. Radio broadcast 2. National television broadcast 3. Regional/local television broadcast 4. National newspaper 5. Regional/local newspaper 6. Internet access 7. Circular Memorandum/announcements from the district government

Village Head/Lurah

95. Others, _______________________________________________________________________

3. As far as you know, has the district government ever held socialization of a local policy (Local Regulation, District Head/Mayor Decree, etc) through mass media (newspaper, radio and television)?

1. Yes, concerning______________________________________________________________ 3. No 8. DO NOT KNOW

M. LOCAL LEGISLATURE (BPD)/KELURAHAN BOARD (DK) INTERVIEWER REMARKS: ACCORDING TO LAW NO.32/2004 BPD = VILLAGE ASSEMBLY BOARD

1. Does this village/kelurahan have any BPD/DK or other similar functioning body? 1. Yes 3. No SECTION N

2. What is this institution’s name? (Is it BPD/DK or mention is there is any other institution) 3. When was the institution established? Month└─┴─┘ Year └─┴─┴─┴─┘ 2. According to your opinion, what role of BPD/DK that stands the most? 1. Public aspiration absorbent

2. Input provider for village head/lurah 3. Mediator for villager and the village/kelurahan government 4. Monitor the work of village head/lurah and local apparatus 5. Recommend village/kelurahan policies/activities 95.Others,_________________________________________________________________________ 98. DO NOT KNOW

5. In the last 6 months how many gatherings/meetings/assembly conducted between the village head/lurah and the BPD/DK?

└─┴─┘ times

N. POLICIES, DELIBERATIONS OF VILLAGE/KELURAHAN DEVELOPMENT AND BUDGET

N1. Village Regulation (PERDES) and Village Governance Policies INTERVIEWER REMARKS: QUESTIONS IN N1 AND N2 ARE ONLY FOR THE VILLAGE HEAD.

ADMINISTRATIVE UNIT IN THIS AREA? 1. VILLAGE 2. KELURAHAN SECTION N3

1. In the last 5 years, has this village issued any Village Regulation/PERDES? 1. Yes 3. No, because _____________________________________________________________

2. In general do the villagers (other than community leaders) be able to participate by giving opinions, suggestion and/or objections in PERDES formulation process and result?

1. Yes 3. No, because ___________________________________________________________________

Village Head/Lurah

N2. Village Budget (APBDes)

1. Did this village have APBDes in 2005? 1. Yes 3. No, because ___________________________________________________________________

2. Was APBDes 2005 being socialized to the villagers? 1. Yes, through ___ ________________________________________________________________ 3. No, because ___________________________________________________________________

3. Was there any accountability process/report for APBDes 2005 from the village head? 1. Yes, to ___________________________________________________________________ every └─┴─┘ months/years 3. No, because ___________________________________________________________________

4. Did the village head submit APBDes 2005 and the accountability report to the higher government structure?

1. Yes, to the District Government 2. Yes, to the Subdistrict Government 3. No, because ___________________________________________________________________

5. Was there any PERDES/Village Policy that being annulled or cancelled by the subdistrict/district

government in the last 2 years? 1. Yes, regarding ________________________________________________________________ 3. No

N3. Development Planning at Village/Kelurahan Level

1. When was the last time this village/kelurahan held a deliberation of village/kelurahan development planning?

Month └─┴─┘ Year └─┴─┴─┴─┘ 6. NOT APPLICABLE SECTION N4

2. Was the meeting preceded by a similar meeting at hamlet/neighborhood community (RW) level? 1. Yes 3. No 8. DO NOT KNOW 3. Other than community leaders, can the villagers in general (...) in the deliberation of development planning?

a. Attend/participate 1. Yes 3. No, because ___________________________________________________________________

b. Deliver suggestion 1. Yes 3. No, because ___________________________________________________________________

N4. Development Planning at Subdistrict Level

1. When was the last time the village head/ lurah attend a gathering/meeting/deliberation of the development planning at subdistrict level (Regional Development Work Unit/UDKP or similar type?

1. Month └─┴─┘ Year └─┴─┴─┴─┘ 6. NOT APPLICABLE SECTION O 8. DO NOT KNOW SECTION O

2. Did the village head/lurah give village proposal/kelurahan program at that gatherings/meetings/ deliberation of development planning?

1. Yes 3. No SECTION O 8. DO NOT KNOW SECTION O

3. Has any of the proposals being realized? 1. Yes, └─┴─┴─┘ percent 3. No 8. DO NOT KNOW

Village Head/Lurah

O. POLITICS

1. In the last 1 year, has any political parties held social activities, political education, training and similar activities in which the villagers participated in?

1. Yes, namely ___________________________________________________________________ 3. No 8. DO NOT KNOW

2. In the last 1 year, has there any member of the Local House of Representatives (DPRD) came and involved in a discussion with the villagers or government?

1. Yes, namely ___________________________________________________________________ 3. No 8. DO NOT KNOW

Village Head/Lurah

DS. SECONDARY DATA INTERVIEWER REMARKS: THIS PART SHOULD ONLY BE ASKED TO THE VILLAGE GOVERNMENT. VILLAGE REVENUE AND EXPENDITURES FOR YEAR 2005

1. Village Revenue 2005

A. Village Own-source Revenue

1. Village revenue from business Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 2. Shared revenue from resources Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. Revenue from self-production and participation Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 4. Revenue from cooperation/gotong royong Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 5. Other legal Own-source revenue Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

B. Grant from the District/City Government 1. Tax shared revenue and regional retribution Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 2. Balancing funds from central and region received by the district/city government Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

C. Grant from Central Government and Provincial Government Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ D. Third party contributions Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ E. Village Loan Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ V. Others,

____________________________________________________________________ Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Total Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Village Head/Lurah

2. Village Expenditures 2005

A. Village apparatus payroll Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ B. Village apparatus allowances Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ C. Village office operational cost Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ D. Construction and maintenance of village buildings/facilities Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ E. Construction and maintenance of public facilities/infrastructure Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ F. Community activities support Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ V. Others,

____________________________________________________________________ Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Total Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. Village Development Program for 2005

A. Village Government Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ B. Government Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ C. NonGovernment Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

FK. COPIES

1. Village/Kelurahan Map

2. The latest village/kelurahan monograph

3. Records or reports of the village revenue and expenditures 2005 (copy this data if the tables of revenue and expenditures 2005 could not be completed during interview)

Village Head/Lurah

OL. DIRECT OBSERVATION INFORMATION AND POSTERS AVAILABILITY

1. IS THERE ANY INFORMATION/POSTERS REGARDING THE CURRENT PROCEDURES FOR PROCESSING (....) AT THE VILLAGE HEAD/LURAH OFFICE?

a. IDENTITY CARD (KTP) 1. YES 3. NO

b. FAMILY CARD (KK) 1. YES 3. NO

c. BIRTH CERTIFICATE 1. YES 3. NO

d. DEATH CERTIFICATE 1. YES 3. NO

2. IS THERE ANY INFORMATION/POSTERS REGARDING THE CURRENT (.....) AT THE VILLAGE HEAD/LURAH?

a. ORGANIZATION STRUCTURE OF THE VILLAGE/KELURAHAN GOVERNMENT 1. YES 3. NO

b. FINANCIAL CONDITION OF THE VILLAGE/KELURAHAN IN 2005 OR 1. YES 3. NO

c. GATHERING OF THE VILLAGERS 1. YES 3. NO

d. PUBLIC/SOCIAL ACTIVITIES, SUCH AS INDEPENDENCE DAY ACTIVITIES, RELIGIOUS CELEBRATIONS, ETC.

1. YES 3. NO

3. IS THERE ANY INFORMATION/POSTERS REGARDING SOCIALIZATION OF (......) PROGRAMS ATTHE VILLAGE HEAD/LURAH OFFICE?

a. PKPS BBM IP (Fuel reduction subsidy for rural infrastructure) 1. YES 3. NO

b. SLT (Unconditional Cash Transfer) 1. YES 3. NO

c. JKPMM or PKPS BBM-BK – Health Sector 1. YES 3. NO

d. OTHERS,___________________________________________________________________

1. YES 3. NO

e. OTHERS,___________________________________________________________________

1. YES 3. NO

Village Head/Lurah


1. WHAT IS THE MOST FREQUENTLY USED LANGUAGE DURING THE INTERVIEW? 1. JAVA 7. MADURA 13. NIAS 19. LAMPUNG 2. SUNDA 8. SASAK 14. PALEMBANG 20. DAYAK 3. BALI 9. MINANG 15. SUMBAWA 21. INDONESIA 4. BATAK 10. BANJAR 16. TORAJA 95. OTHERS,________________ 5. BUGIS 11. BIMA 17. LAHAT 6. CHINESE 12. MAKASAR 18. BETAWI


3. IF RESPONDENT IS NOT THE HEAD OF VILLAGE/LURAH, HOW WELL IS HIS/HER UNDERSTANDING OF THE VILLAGE CONDITION/PROBLEMS?

1. GOOD 3. POOR

2. MODERATE/NOT SO GOOD 4. NOT APPLICABLE 4. WHICH QUESTIONS WERE CONSIDERED DIFFICULT, EMBARASSING, OR CONFUSING

FOR RESPONDENT TO ANSWER? (WRITE THE SECTION AND THE NUMBER OF THE QUESTIONS)


Village Head/Lurah



CONFIDENTIAL


H E A D OF HAMLET

Head of Hamlet/Equivalent ID └─┴─┘└─┴─┘ 13 └─┴─┘ A. HAMLET/EQUIVALENT LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/Kelurahan *) Code └─┴─┴─┘ 5. Hamlet/_____________________________________ *) Code 1 2 6. Address 7. Postal Code └─┴─┴─┴─┴─┘ 8. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ *) Select one B. HEAD OF HAMLET/EQUIVALENT IDENTITY AND GENERAL INFORMATION B1. Head of Hamlet/Equivalent Identity

INTERVIEWER REMARKS: QUESTIONS IN SECTION B1 ARE ONLY FOR THE HEAD OF HAMLET/EQUIVALENT AND SHOULD NOT BE ASKED TO HIS/HER REPRESENTATIVE.

IS THE RESPONDENT THE HEAD OF HAMLET/EQUIVALENT HER/HIMSELF? 1. YES 3. NO SECTION B2

1. What is your complete name? 2. Since when have you become the head of this hamlet/equivalent? Month └─┴─┘ Year └─┴─┴─┴─┘ 3. Gender 1. Male 3. Female

4. What is your age at the moment? └─┴─┘ Years

Head of Hamlet

5. What was the highest level of education you have completed? 1. Elementary School/Islamic Elementary (MI) 5. Diploma III 2. Junior High School/ Islamic Junior (MTs) 6. Diploma IV/S1-Bachelor 3. Senior High School/SMK/Islamic High (MA) 7. Post Graduate (S2/S3) 4. Diploma I/II 95. Others, ____________________________

6. Do you have other income generating occupation in the last 1 year? 1. Yes 3. No NO. 9

7. In what field/sector does this other occupation belong to? INTERVIEWER REMARKS: IF THE RESPONDENT WORKS IN SEVERAL

FIELDS/SECTORS, PLEASE ASK WHICH FIELD/SECTOR IN WHICH HE/HER ALLOCATED HIS/HER TIME THE MOST (IN HOURS/WEEKS) DURING THE LAST 1 YEAR

1. Agriculture 6. Trade 2. Mining and Quarrying 7. Transportation and Communications 3. Manufacture 8. Finance 4. Electricity, gas and water 9. Service 5. Construction 95. Others, ____________________________

8. What is your employment status on that other occupation? 1. Self employed 5. Private Employee 2. Business with temporary labor/unpaid labor 6. Farm freelance workers 3. Business with permanent labor/paid labor 7. Non-farm freelance workers 4. Civil Servant 95. Others, ___________________________

9. Do you receive honorarium/operational allowance as the head of hamlet/equivalent? 1. Yes 3. No NO. 13

10. How much is the honorarium/operational allowance? Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ per month/per year (CROSS OUT THE UNNECESSARY)

11. Where do the honorarium/operational allowance come from? A. DISTRICT/CITY BUDGET B. VILLAGE/KELURAHAN BUDGET C. PUBLIC SUBSCRIPTION V. OTHERS, _____________________________________________________________________ Y. DO NOT KNOW

12. What is the percentage of your income as head of hamlet /equivalent compared to the total income from your total work last month? └─┴─┴─┘ percent

13. Does this hamlet/equivalent have its own office? INTERVIEWER REMARKS: THE OFFICE OF THE HEAD OF THE HAMLET/EQUIVALENT

DOES NOT LOCATED IN THE PRIVATE RESIDENCE OF THE HEAD OF HAMLET/EQUIVALENT

1. Yes 3. No NO. 15

14. Who built that office? 1. Village/Kelurahan Government 2. Villagers 5. Others, _______________________________________________________________________

15. How long is the current governance period for the head of hamlet/equivalent? └─┴─┘ years

Head of Hamlet

16. When is the next election for the head of hamlet/equivalent? 1. Month └─┴─┘ Year └─┴─┴─┴─┘ 8. DO NOT KNOW 6. NOT APPLICABLE

17. How many hours, in average, in a week, do you work for issues related to this hamlet/equivalent? └─┴─┘ hours

18. In case of emergency, can the villagers contact the head of hamlet/equivalent at any time? 1. Yes 3. No B2. Respondent Identity (If the head of Hamlet/Equivalent Absent/Unavailable) INTERVIEWER REMARKS: QUESTIONS IN SECTION B2 ARE ONLY FOR THE RESPONDENT THAT REPRESENTING THE HEAD OF HAMLET/EQUIVALENT

IS THE RESPONDENT THE HEAD OF HAMLET/EQUIVALENT HER/HIM SELF? 1. YES SECTION B3 3. NO

1. What is your complete name? 2. What is your the position in this hamlet/equivalent? INTERVIEWER REMARKS: IT IS UNNECESSARY TO ASK IF INFORMATION CONCERNING

THE SOCIAL POSITION/OFFICE OF THE RESPONDENT IS ALREADY KNOWN BEFOREHAND, SPECIFICALLY IF THE RESPONDENT IS A COMMUNITY LEADER

1. Hamlet/Equivalent Secretary 2. Hamlet/Equivalent Treasurer 3. Former Hamlet Head 4. Community Leader (Customary leader, religious leader, etc) 5. Others, _______________________________________________________________________

3. Gender 1. Male 3. Female

4. What is your age at the moment? └─┴─┘ Years 5. What is the highest level of education you have completed? 1. Elementary School/Islamic Elementary (MI) 5. Diploma III

2. Junior High School/ Islamic Junior (MTs) 6. Diploma IV/S1-Bachelor 3. Senior High School/SMK/Islamic High (MA) 7. Post Graduate (S2/S3) 4. Diploma I/II 95. Others, ____________________________

B3. General Information 1. What is potable water source that most frequently used by a most villagers of this

hamlet/equivalent?

1. Water utilities(PAM)/piped water into dwelling/yard/plot 2. Public hydrant 7. Bottled water 3. Drilled well 8. Unprotected dug well 4 Protected dug well 9. Unprotected spring 5. Protected spring 10. Water vendor truck 6. Rain water collection 11. Surface water (river, stream, dam,

lake/fishpond, channel, water channel)

2. What type of toilet that most frequently used by villagers in this hamlet/equivalent? 1. Family toilet 3. Public toilet 2. Shared toilet 4. No facilities available NO. 4

Head of Hamlet

3. What type of latrine used by most villagers in this hamlet/equivalent? 1. Pour Flush Latrine 3. Pit Latrine/cubluk 2. Throne Latrine

4. Where is feces final disposal for most villagers in this hamlet/equivalent?

1. Septic Tank/SPAL 4. Open pit hole 2. Pond/rice fields 5. Coast/field/garden 3. River/lake/sea 95. Others, __________________________

5. Is there any “market day” in this hamlet/equivalent? 1. Yes 3. No SECTION C

6. When is the “market day” held?

C. ACCESS TO PUBLIC FACILITIES We would like to ask the public facilities that most frequently used by the villagers of this hamlet/equivalent.

Facilities 1. Do you aware of the existence of [….] ?

1. Yes 3. No

2. What is the name and location of [...]?

3. What kind of transportation used the most by the villagers of this hamlet/equivalent to get to [...]?

A. On foot D. Car B. bicycle E. Boat C. Motorcycle V. Others, ________

4. How long does it take from your house/office to [...]?

(CONVERT INTO MINUTES)

a. The nearest asphalt road 1 3 A B C D E V ____________________ └─┘.└─┴─┴─┘ b. The nearest market where villagers

normally purchase daily needs other than food

1 3 A B C D E V ____________________ └─┘.└─┴─┴─┘

c. Village Head/Lurah Office 1 3 A B C D E V ____________________ └─┘.└─┴─┴─┘ d. The Nearest Police Station 1 3 A B C D E V ____________________ └─┘.└─┴─┴─┘ e. The Nearest Post Office 1 3 A B C D E V ____________________ └─┘.└─┴─┴─┘ f. The Nearest Bank 1 3 A B C D E V ____________________ └─┘.└─┴─┴─┘

5. INTERVIEWER REMARKS: ASK THIS QUESTION ONLY TO THE HEAD OF HAMLET/ EQUIVALENT

How far is the distance between your house/office to the farthest villager’s house? (IN METERS)

└─┴─┘.└─┴─┴─┘ meters

Head of Hamlet

D. ASSESSMENT OF PUBLIC SERVICES (OTHER THAN HEALTH AND EDUCATION SERVICES) PROVIDED BY THE DISTRICT/CITY GOVERNMENT We would like to ask you to assess public services (other than healthcare and education services) provided by the District Government for the villagers of this hamlet/equivalent.

1. Is the current (.......) service in this district/city sufficient?

a. Clean water 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

b. Sanitation/sewerage 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

c. Roads 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

d. Waste management 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

e. drainage management/flood mitigation 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

f. Irrigation system (for agriculture) 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

g. Public Transportation 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

h. Street and public area lightening 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

i. Environment management (forests, mining, energy) 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

j. Licensing 1. Yes 3. No 6. NOT APPLICABLE 8. DO NOT KNOW

2. From several types of public services mentioned before, according to you, which public services is (......)?

Respondent can mention other than the above mentioned one.

1. Clean water 2. Sanitation/sewerage 3. Road 4. Waste management 5. Drainage management/flood mitigation 6. Irrigation system (for agriculture)

7. Public transportation 8. Street and public area lightening 9. Environment management (forests, mining,

energy) 10. Licensing 95. Others

a. Most sufficient 1 2 3 4 5 6 7 8 9 10 95,_________________________________________________

b. Most insufficient 1 2 3 4 5 6 7 8 9 10 95,_________________________________________________

Head of Hamlet

E. ASSESSMENT OF THE HEALTH SERVICE INTERVIEWER REMARKS: HEALTH FACILITIES CAN BE IN FORM OF PUBLIC HEALTH FACILITIES (SUCH AS STATE-OWNED PUBLIC HOSPITAL, PUSKESMAS, PUSTU, PUSLING, ETC.) OR PRIVATE SECTOR FACILITIES (SUCH AS PRIVATE HOSPITALS, PRIVATE DOCTORS, PRIVATE MIDWIVES, ETC.)

1. Please mention 3 health facilities, which are most frequently used by villagers of this hamlet/equivalent whether located in this village/kelurahan or other villages/kelurahan.

2. Where is the location of each health facility?

3. How far is the head of hamlet/equivalent’s house/office to these health facilities? (IN METERS)

4. How long does it take from the head of hamlet/equivalent’s house/office to these health facilities? (IN MINUTES)

a. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘ b. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘ c. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘

5. According to you, how is the current (....) compared to two years ago?

a. Availability of health facilities (public or private) within the reach of the villagers of this hamlet /equivalent

1. Improved 3. Worse 8. DO NOT KNOW 2. The same 6. NOT APPLICABLE

b. Socialization of health/environmental health (information outreach regarding healthy behavior, nutrition, etc.)


c. Quality improvement (such as supplemental food program, provision of zinc pills and Vitamin A, etc.) of the consumed nutrition


d. Prevention and mitigation (e.g. immunization, house fogging to prevent dengue fever, etc.) of contagious diseases


6. Has any epidemic occurred in this hamlet/equivalent during the last two years? 1. Yes, an epidemic of ______________________________________________________________ 3. No SEEKS F

7. Has any staff/official from the district/city, province or central government come to this hamlet /equivalent to address the epidemic?

1. Yes, namely____________________________________________________________________ 3. No SECTION F

8. Was the government of the hamlet/equivalent involved in the effort to address the epidemic? 1. Yes 3. No

9. Were you satisfied with that effort? 1. Yes, because___________________________________________________________________ 3. No, because ___________________________________________________________________

Head of Hamlet

F. ASSESSMENT ON EDUCATION SERVICES INTERVIEWER REMARKS: SCHOOLS CAN BE IN THE FORM OF STATE, PRIVATE OR MADRASAH (RELIGIOUS) SCHOOLS.

1. Please mention 3 schools (for each primary and junior high school) which are most frequently used by villagers of this hamlet/equivalent, whether located in this village/kelurahan or other villages/kelurahan.

2. Where is the location of each school? 3. How far is the head of hamlet/ equivalent’s house/office to these schools? (IN METERS)

4. How long does it take from the head of hamlet/equivalent’s house/office to each school? (IN MINUTES)

Primary School

a. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘ b. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘ c. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘

Junior High School

d. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘ e. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘ f. └─┴─┘.└─┴─┴─┘ └─┘.└─┴─┴─┘

5. According to you, how is the current (....) compared to two years ago?

a. Availability of schools (public, private or madrasah) that can be accessed by the villagers of this hamlet/equivalent


b. Condition of school buildings and equipment (such as decent school building, sufficient classrooms, library, etc.)


c. Total number and quality of teacher/education staff 1. Improved 3. Worse 8. DO NOT KNOW 2. The same 6. NOT APPLICABLE

d. Quality of school (such as number of graduate student, number of graduate students who succeeded in entering the subsequent level, etc.)


e. Availability of scholarship or waiver on school fees for poor families 1. Improved 3. Worse 8. DO NOT KNOW 2. The same 6. NOT APPLICABLE

f. Road/transportation facilities to reach the schools (such as road condition and availability of public transportation, etc.)


Head of Hamlet

G. PROCESSING IDENTITY CARD (KTP)

1. In average, how much time does it require to process Identification Card (KTP): └─┴─┘ days 2. In general, how much would it cost to process a KTP? Rp └─┴─┴─┘.└─┴─┴─┘ 3. Is there any villager of this hamlet/equivalent who does not process his/her KTP by her/himself,

and use the intermediary assistance instead (such as through the RT/RW/ hamlet/rural apparatus, village/kelurahan officials, services bureau)?

1. Yes there is/are, approximately └─┴─┴─┘percent 3.There are none NO. 5

4. According to you, what is his/her reason for not processing his/her KTP by her/himself (use assistance/intermediary instead)?

A. CHEAPER (FOR EXAMPLE OTHER COSTS, SUCH AS TRANSPORTATION COST, IS MORE EXPENSIVE THAN PAYING A MIDDLEMAN)

B. TIME EFFICIENCY (FOR EXAMPLE PREFER TO USE THE TIME TO WORK INSTEAD OF PROCESSING A KTP)

C. DO NOT WISH TO EXPERIENCE THE PROCEDURE TO PROCESS KTP (FOR EXAMPLE RESPONDENTS DO NOT KNOW A KTP PROCESSING PROCEDURE, OR THINK THAT SUCH PROCEDURE IS TOO COMPLICATED OR UNCLEAR)

V. OTHERS, _____________________________________________________________________

5. In the last 2 years, has the government (village/kelurahan, hamlet, district/city) gave any socialization/information dissemination to villagers of this hamlet/equivalent on the procedure to process KTP?

1. Yes, by using/through __________________________________________________________ 3. No

H. POLICE SERVICES

1. Is there any routine patrols/monitoring from the police for this hamlet/equivalent? 1. Yes 3. No

2. Have you ever heard of a Police members asking for graft money/“cigarette money” from the villager who is using police service (e.g. when processing crime, security service during festive, etc.)?


I. POOR FAMILIES (KELUARGA MISKIN/ GAKIN) INTERVIEWER REMARKS: QUESTIONS IN SECTION I AND J SHOULD ONLY BE ASKED TO THE HEAD OF HAMLET/EQUIVALENT, AND NOT TO THE RESPONDENT REPRESENTING HIM/HER.

IS THE RESPONDENT THE HEAD OF HAMLET/EQUIVALENT? 1. YES 3. NO SECTION K

1. What is the percentage of total GAKIN from total head of household (KK) in this hamlet/ equivalent? (percentage) └─┴─┘percent

2. In 2005, was there any government special program for GAKIN in this hamlet/equivalent? 1. Yes, a. Program ________________________________________________________________ b. Program ________________________________________________________________ c. Program ________________________________________________________________ 3. No

Head of Hamlet

8. DO NOT KNOW

3. In 2005, was there any resident of this hamlet/equivalent arranged for statement of poor (SKTM) (e.g. for medical treatment or education purposes)?

1. Yes 3. No

4. In the last two years, have you ever heard/informed about villager who got discriminated/differentiated on health or education service because he/she was poor?

1. Yes 3. No SECTION J

5. Mention the case of service discrimination/differentiated on the health and education sectors: a. Health Case, _______________________________________________________________ b. Education Case, _______________________________________________________________

J. COMPENSATION PROGRAM TO REDUCE FUEL SUBSIDY (PKPS BBM) J1. PKPS BBM – Rural Infrastructure (IP) Improvement

1. Does this hamlet/equivalent receive PKPS BBM-IP? 1. Yes 3. No SECTION J2

2. What project(s) has/have been selected to be financed by the PKPS BBM-IP? A. RURAL ROADS F. SIMPLE DAM B. BRIDGES G. RURAL IRRIGATION C. BOAT MOORINGS H. POTABLE WATER SUPPLY D. EMBUNG V. OTHERS, __________________________ E. SURFACE WATER

3. How did the project selected/authorized? 1. THROUGH VILLAGE/KELURAHAN MEETINGS 4. SELECTED BY THE VILLAGE HEAD/ LURAH 2. THROUGH CLOSED MEETING BETWEEN 5. SELECTED BY THE SUB DISTRICT HEAD THE VILLAGE HEAD/LURAH AND HEAD OF 6. SELECTED BY THE PUBLIC WORKS UNIT HAMLET/EQUIVALENT 3. THROUGH CLOSED MEETING AMONG 95. OTHERS, __________________________ HEAD OF HAMLET/EQUIVALENT 98. DO NOT KNOW

4. Do you know the cost or total budget of the project(s)? 1. Yes, Rp. └─┴─┴─┘. └─┴─┴─┘.└─┴─┴─┘ 3. No

5. Who execute the project? 1. VILLAGE/KELURAHAN APPARATUS 2. CONTRACTOR FROM THIS VILLAGE/KELURAHAN 3. CONTRACTOR FROM OTHER VILLAGES/KELURAHAN 5. OTHERS, _____________________________________________________________________ 8. DO NOT KNOW

6. Is there any villager of this hamlet/equivalent works in the project? 1. Yes 3. No

7. Are you satisfied with the implementation of the projects? 1. Yes

Head of Hamlet

3. No, because ___________________________________________________________________

8. Is there any difficulty/obstacle/constraint during the implementation of the PKPS BBM-IP? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

9. What is your suggestion to improve the PKPS BBM-IP? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

J2. PKPS BBM – Unconditional Cash Transfer (UCT/SLT)

1. Does any of the villagers in this hamlet/equivalent receive PKPS BBM-SLT? 1. Yes 3. No SECTION J3

2. Have you ever attended a meeting/socialization about PKPS BBM-SLT? 1. Yes 3. No

3. Did the village/kelurahan government inform the villagers about the PKPS BBM-SLT prior to the initial data collection?

1. Yes 3. No NO.5

4. What device/media was used? A. BROCHURES/BOARDS, FLYER B. MEETINGS/GATHERINGS/RESIDENT ACTIVITIES/ACTIVITIES IN PLACES OF WORSHIP C. DOOR TO DOOR VISIT V. OTHERS, ____________________________________________________________________

5. Who did the data collection on poor families whom become the candidate to receive PKPS BBM-SLT?

A. VILLAGE/KELURAHAN APPARATUS E. STATISTIC OFFICER/ BPS OFFICER/ B. PKK/POSYANDU CADRE ENUMERATOR/BPS PARTNER/PARTNER C. PUSKESMAS OFFICER/MIDWIFE/PLKB ASSISTANT D. COMMUNITY LEADER V. OTHERS, ________________________

6. Did you play any role in the selection/appointment of the data officers? 1. Yes 3. No

7. Can the criteria set by the government to select the households as the candidate of PKPS BBM-SLT receiver, applied completely to this hamlet/equivalent?

1. Yes 3. No, because ________________________________________________________________ 6. NOT APPLICABLE NO.9 8. DO NOT KNOW

8. Do you consider the criteria set by the government already accurate? 1. Yes 3. No, because ________________________________________________________________

9. Was there any difference between the list of proposal and the list of recipients during the first phase of PKPS BBM-SLT for the period October-December 2005?


10. Was there any sequel data collection after the first phase period of October-December 2005? 1. Yes 3. No 8. DO NOT KNOW

11. Who distributes the fuel compensation/UCT cards? A. VILLAGE/KELURAHAN APPARATUS E. BPS OFFICER/ENUMERATOR B. PKK/POSYANDU CADRE /BPS PARTNER/PARTNER C. PUSKESMAS OFFICER/MIDWIFE/PLKB ASSISTANT D. COMMUNITY LEADER V. OTHERS, ________________________

Head of Hamlet

12. How did they distribute the cards? 1. DELIVERED TO PEOPLE’S HOUSE 2. COLLECT AT ____ (SEE ANSWER NO.11) 3. AT THE VILLAGE MEETING 5. OTHERS, ____________________________________________________________________

13. Before the disbursement of the PKPS BBM-SLT funds, has there been any notification/announcement from the village/kelurahan government to the villagers about the venue, time and requirements for collecting of the money?

1. Yes 3. No NO.15

14. What device/media was used? A. BROCHURES/BOARDS,INFORMATION FLYER B. MEETINGS/GATHERINGS/RESIDENT ACTIVITIES/ACTIVITIES IN PLACES OF WORSHIP C. HOUSE TO HOUSE CALLS V. OTHERS, ____________________________________________________________________

15. What is the difficulty/obstacle/constraint faced during the implementation of the PKPS BBM-SLT?

1. _____________________________________________________________________________ 2. _____________________________________________________________________________

16. What is your suggestion of you to improve the PKPS BBM-SLT? 1. _____________________________________________________________________________ 2. _____________________________________________________________________________

J3. PKPS BBM – Health Sector (BK)

1. Does any of the villagers in this hamlet/equivalent receive PKPS BBM-BK or Health Insurance for the Poor Program (JPKMM)?

1. Yes 3. No SECTION J4

2. Was there any data collection process for the family whom become the candidate to receive PKPS BBM-BK?

1. Yes 3. No NO.5

3. Who did the data collection? A. DISTRICT/CITY HEALTH OFFICER D. VILLAGE/KELURAHAN APPARATUS B. BKKBN (Family Planning) OFFICER V. OTHERS, _________________________ C. PUSKESMAS OFFICER

4. Was there any difficulty in the data collection and selection process of the people who is eligible to participate in this PKPS BBM-BK/JPKMM?

1. Yes 3. No, because _________________________________________________________________ 8. DO NOT KNOW

5. Have all villagers who have been declared to be eligible to participate in the PKPS BBM-BK/JPKMM received their JKPMM cards?

1. Yes 3. No

Head of Hamlet

J4. Complaint/Proposal Linked to PKPS BBM INTERVIEWER REMARKS: QUESTIONS NO.1 - 3 ARE RELATED TO PKPS BBM-IP, SLT AND BK.

1. Is there any [...] linked to the PKPS BBM for Rural Infrastructure, Unconditional Cash Transfer or Health Sector/JPKMM in this hamlet/equivalent?

a. Complaint/protest from villagers 1. Yes 3. No

b. Disturbances/fights 1. Yes 3. No

c. Rallies of protests 1. Yes 3. No

d. Villagers who deliver information regarding the program implementation 1. Yes 3. No

2. Has the hamlet/equivalent officials ever delivered complaint/protest/suggestion/advice from the people, to the officer/institutions in charge for the implementation of PKPS BBM in this hamlet /equivalent?

1. Yes, , to _________________________________________________________________ 3. No SECTION K

3. Was the response from the officer/institutions sufficient? 1. Yes 3. No 6. NOT APPLICABLE K. PROGRAMS/ACTIVITIES AND COMMUNITY PARTICIPATION

Programs/Activities

INTERVIEWER REMARKS: OTHER THAN PKPS BBM–IP PROJECTS

1. During 2005, in this village/kelurahan was there any […]? 2. Who financed the activity? A. VILLAGERS B. VILLAGE/KELURAHAN GOVERNMENT FUNDS C. DISTRICT/CITY GOVERNMENT FUNDS D. PROVINCIAL GOVERNMENT FUNDS E. CENTRAL GOVERNMENT FUNDS F. DONORS/NON GOVERNMENT ORGANIZATIONS V. OTHERS, _________________ Y. DO NOT KNOW

a. Village/kelurahan Infrastructure Improvement Program (such as construction, maintenance, improvement of roads, sports facilities, education facilities, etc.)

1. Yes, namely program ________________________________ __________________________________________________ 3. No

A B C D E F V ___________________________________________________ Y

b. Health services (such as neighborhood fogging to terminate Dengue Fever, baby weighing post, integrated health post/Posyandu, etc.)

1. Yes, program_______________________________ __________________________________________________ 3. No

A B C D E F V ___________________________________________________ Y

c. Clean water supply and sanitation (such as public pumps for MCK (Bathing, Washing, Toilet) needs, rain water collection or other sources to overcome the drought during the dry season, etc).

1. Yes, program_______________________________ __________________________________________________ 3. No

A B C D E F V ___________________________________________________ Y

Head of Hamlet

3. According to you, is it difficult or easy to organize meeting with villagers to discuss development activities in this hamlet/equivalent?

1. Easy 2. Normal 3. Difficult

4. What kind of support/participation do the villagers provide for the development of this hamlet /equivalent?

A. THERE IS NO SUPPORT NO.6 B. MANPOWER (VOLUNTARY LABOR/GOTONG ROYONG) C. PROVIDE OPINIONS/SUGGESTIONS D. PAYMENT OF SUBSCRIPTIONS FOR ACTIVITIES/DEVELOPMENT V. OTHERS, _____________________________________________________________________

5. Do you consider that the support/participation from villagers sufficient? 1. Sufficient 3. Insufficient 8. DO NOT KNOW

6. According to you, has the support/participation of villagers for the development of this hamlet /equivalent improved or deteriorated during the last 2 years?

1. Improved 3. Deteriorated 2. The Same 8. DO NOT KNOW

L. RELATIONSHIP OF THE HEAD OF HAMLET/EQUIVALENT WITH THE PUBLIC SERVICE PROVIDERS INTERVIEWER REMARKS: QUESTION SECTION L ONLY FOR THE HEAD OF HAMLET/EQUIVALENT AND NOT TO THE RESPONDENT REPRESENTING HIM / HER.

IS THE RESPONDENT THE HEAD OF THIS HAMLET/EQUIVALENT? 1. YES 3. NO SECTION M

1. During 2005, was there any meeting with (...) in terms of duties?

2. What was the topic that being discussed?

a. Puskesmas (Community Health Center) 1. Yes 3. No b. Public Schools (Primary, Junior High,

Senior High School) 1. Yes 3. No

c. Police 1. Yes 3. No d. Village/Kelurahan Government 1. Yes 3. No

3. Have you received criticism, complaint and suggestion from villagers related to services from (....)?

4. What have you done to the criticism, complaints and suggestions (....)?

A. FORMALLY SUBMITTED IT B. INFORMALLY SUBMITTED IT C. SUGGESTED THE VILLAGERS TO

DELIVER IT DIRECTLY D. FOLLOWED UP E. IGNORED V. OTHERS,

5. As far as you know, has (...) responded to the criticism, complaints and suggestions from the villagers?

Head of Hamlet

___________________________

a. Puskesmas (Community Health Center) 1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

b. Public Schools (Primary, Junior High, Senior High School)

1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

c. Police 1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No

d. Village/Kelurahan Government 1. Yes 3. No A B C D V ___________________________ 1. Yes 3. No M. CORRUPTION CASES LINKED TO PUBLIC SERVICES

1. Have you ever heard/informed any case of corruption/misuse of authority in this district/city in the last 2 years?

a. Public Hospitals/Puskesmas 1. Yes, case______________________________________________________________________ 3. No 8. DO NOT KNOW

b. Public Schools (Primary, Junior High, Senior High School) 1. Yes, case______________________________________________________________________ 3. No 8. DO NOT KNOW

c. Police 1. Yes, case______________________________________________________________________ 3. No 8. DO NOT KNOW

d. Village/Kelurahan Government 1. Yes, case______________________________________________________________________ 3. No 8. DO NOT KNOW

N. TRUST AMONG RESIDENTS

1. According to you, do (...) trustworthy or untrustworthy?

a. Villagers of this village/kelurahan 1. Trustworthy 3. Untrustworthy

b. Villagers of neighboring villages/kelurahan 1. Trustworthy 3. Untrustworthy

c. Migrants of other regions/ethnic groups 1. Trustworthy 3. Untrustworthy

d. People of different religions 1. Trustworthy 3. Untrustworthy

Head of Hamlet

O. DISPUTES/CONFLICTS We would like to ask about disputes/conflicts that occurred in this village/kelurahan during the last 2 years.

2. In general, who would usually takes part in the effort to resolve the dispute/conflict occurred?

Type of dispute/conflict 1. Has any […] occurred in this village/kelurahan in the last 2 years?


A. PARALEGAL B. COMMUNITY/RELIGIOUS/

CUSTOMS FIGURES C. VILLAGE OFFICIALS D. NON-GOVERNMENT

ORGANIZATION (FACILITATOR)

E. POLICE F. FAMILY MEMBER/FRIEND


1. Has any […] occurred in this village/kelurahan in the last 2 years?



1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

b. Disputes/conflicts as a result of general criminal acts (theft, homicide, etc.)

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

c. Disputes/conflicts as a result of misuse of power/authority

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

d. Disputes/conflicts as a result of marriage/divorce/legacy

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

e. Disputes/conflicts as a result from domestic violence

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8

f. Disputes/conflicts related with Pilkades (Village Head Election)/Pilkada (Regional Head Election/Pemilu (General Election)

1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8


1 3 8 A B C D E F G H I J V __________________________________________________ Y

1 2 3 4 8


5. According to you, does the judicial institution able to resolve an issue in a fair manner? 1. Yes 3. No 8. DO NOT KNOW

6. In a dispute, do you know your legal rights? 1. Yes 3. No

Head of Hamlet

P. SOURCE OF INFORMATION

1. Is this hamlet/equivalent within the reach of (...)?

a. Radio broadcast 1. Yes 3. No

b. National television broadcast 1. Yes 3. No

c. Regional/local television broadcast 1. Yes 3. No 6. NOT APPLICABLE

d. National newspaper 1. Yes 3. No

e. Regional/local newspaper 1. Yes 3. No 6. NOT APPLICABLE

f. Internet access 1. Yes 3. No 8. DO NOT KNOW

2. What source of information that you most frequently used to find out about conditions and policy progress at district/city level?

1. Radio broadcast 2. National television broadcast 3. Regional/local television broadcast 4. National newspaper 5. Regional/local newspaper 6. Internet access 7. Circular memo/announcements from the District/City Government 95. Others, _______________________________________________________________________

3. As far as you know, has the district government ever held socialization of a local policy (Local Regulation, District Head/Mayor Decree, etc) through mass media (newspaper, radio and television)?

1. Yes, concerning______________________________________________________________ 3. No 8. DO NOT KNOW

Q. LOCAL LEGISLATURE (BPD)/KELURAHAN BOARD (DK)

1. Does this village/kelurahan have any BPD/DK or other similar functioning body? 1. Yes 3. No SECTION TLP 8. DO NOT KNOW SECTION TLP

2. According to your opinion, what role of BPD/DK that stands the most? 1. Public aspiration absorbent 2. Input provider for village head/lurah 3. Mediator for villager and the village/kelurahan government 4. Monitor the work of village head/lurah and local apparatus 5. Recommend village/kelurahan policies/activities 95.Others,_________________________________________________________________________ 98. DO NOT KNOW

Head of Hamlet

O. INFORMATION FOR REVISIT

Name 1 : ________________________________________________________________

Address 1 : ________________________________________________________________

Telephone 1 : └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘

1. We might visit your household again someday. If on our next visit your household is no longer located here anymore, please inform us contact detail of the person whom we should contact to get your new address?

Name 2 : ________________________________________________________________

Address 2 : ________________________________________________________________

Telephone 2 : └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ BHS. LANGUAGE USED AND INFORMATION OF THE MAIN RESPONDENT

1. WHAT IS THE MOST FREQUENTLY USED LANGUAGE DURING THE INTERVIEW?

1. JAVA 7. MADURA 13. NIAS 19. LAMPUNG 2. SUNDA 8. SASAK 14. PALEMBANG 20. DAYAK 3. BALI 9. MINANG 15. SUMBAWA 21. INDONESIA 4. BATAK 10. BANJAR 16. TORAJA 95. OTHERS,________________ 5. BUGIS 11. BIMA 17. LAHAT 6. CHINESE 12. MAKASAR 18. BETAWI


3. IF RESPONDENT IS NOT THE HEAD OF HAMLET/EQUIVALENT, HOW WELL IS HIS/HER UNDERSTANDING OF THE VILLAGE CONDITION/PROBLEMS?

1. GOOD 3. POOR

2. MODERATE/NOT SO GOOD 4. NOT APPLICABLE

4. WHICH QUESTIONS WERE CONSIDERED DIFFICULT, EMBARASSING, OR CONFUSING FOR RESPONDENT TO ANSWER? (WRITE THE SECTION AND THE NUMBER OF THE QUESTIONS)


Head of Hamlet



CONFIDENTIAL


U N C O N D I T I O N A L C A S H T R A N S F E R

Household ID └─┴─┘└─┴─┘ 14 └─┴─┘

Name Address

A. HOUSEHOLD LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/kelurahan *) Code └─┴─┴─┘ 5. Hamlet/equivalent Code 1 2 6. Address

7. Postal code └─┴─┴─┴─┴─┘ 8. Telephone and/or cellular phone a. Home 1. Yes, └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 3. No

b. Cellular phone 1. Yes, └─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┴─┘ 3. No *) Select One

Unconditional Cash Transfer

B. HOUSEHOLD ROSTER INTERVIEWER REMARKS: CHOOSE AN ANSWER FOR HOUSEHOLD ROSTER

No.3 What is your relation with Head of Household (KRT) No.6 Ethnicity No.9 Highest level of education completed

1. Head of Household 2. Husband/Wife 3. Biological Children 4. Foster/Adopted Children 5. Children-in-law 6. Parents/Parents-in-law

7. Siblings 8. Siblings-in-law 9. Grandchildren 10. Grandparents 11. Other relatives (cousin,

niece/nephew, etc.) 12. Non-relatives (maid, driver,

etc.)

1. Jawa 2. Sunda 3. Bali 4. Batak 5. Bugis 6. Chinese 7. Madura 8. Sasak

9. Minang 10. Banjar 11. Bima-Dompu 12. Makassar 13. Nias 14. Palembang 15. Sumbawa 16. Toraja

17. Betawi 18. Dayak 19. Melayu-Deli 20. Komering 21. Ambon 22. Manado 23. Aceh 95. Lainnya, _______________

1. Elementary/Islamic Elementary (MI)

2. Junior High/Islamic Junior high (MTs)

3. HighSchool/SMK/Islamic High School (MA)

4. Diploma I/II 5. Diploma III 6. Diploma IV/S1/Bachelor 7. Post Graduate (S2/S3) 95. Others, _______________

INTERVIEWER REMARKS: A HOUSEHOLD IS A GROUP OF PEOPLE LIVING UNDER THE SAME ROOF, EATING IN THE SAME KITCHEN, AND DECIDE ECONOMICAL DECISION TOGETHER, START FROM THE HEAD OF HOUSEHOLD (KRT), KRT PARTNER, CHILDREN, CHILDREN IN LAW, GRANDCHILDREN, ETC.

1. HH member number

2. Household/HH Member’s complete name?

3. Relation with Head of household?

4. Gender?

M F

5. Religion? 1. Moslem 2. Catholic 3. Christian 4. Buddhist 5. Hindu 95.Others, _____

6. Ethnicity?

7. Age (years)?

8. School enrollment? 1. Have never/not

yet enrolled to any school NO.11

2. Still in school 3. No longer in

school


10. Highest level/class completed? 1. 1 5. 5 2. 2 6. 6 3. 3 7. Finish 4. 4 8. Unfinished

11. Last year, did you work at any time? 1. Yes 3. No

1.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

2.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3

3.

└─┴─┘

1 3 1 2 3 4 5

95 __________

└─┴─┘

_________________

└─┴─┘

1 (NO.11) 2 3 └─┘

____________

1 2 3 4 5 6 7 8

1 3


C. TARGETING AND DATA COLLECTION C1. Compulsory Questions

1. Number of household? └─┴─┘households 2. Number of household’s member? └─┴─┘persons 3. The total area of the largest residence? └─┴─┴─┘m2 4. Main material of the floor at the largest residence? 1. Soil/bamboo/wood planks 2. Cement/ceramic tile/polished wood

5. Main material of the wall at the largest residence? 1. Bamboo/sago palm/low quality wood 2. Wall/high quality wood

6. Toilet facilities? 1. Shared/public/others 2. Private/household

7. Source of drinking water? 1. Well or unprotected spring/river/rain water collection 2. Bottled water/piped water/pump/well or protected spring

8. Main lighting? 1. Non- electricity 2. Electricity (PLN/Non PLN)

9. Type of fuel that mainly use for cooking? 1. Charcoal 2. Kerosene 3. Gas/electricity

10. How many times does this household buy meat/chicken/milk in a week? 1. Never 2. Once 3. Twice or more

11. How many times does this household member eat in a day? 1. Once 2. Twice 3. Three times or more

12. How many pair of clothes does this household member/most of household members bought in one year?

1. Never 2. One pair 3. Two pairs or more

13. If a household member is ill, is it affordable to go to Puskesmas or clinic for treatment? 1. Yes 3. No

14. Main occupation of the head of household? 1. Agriculture (Rice and palawija) 4. Fishery 2. Plantation 5. Manufacture 3. Livestock Farm 95. Others, ___________________________

15. The highest education completed by the head of household? 1. Elementary School/MI and below 2.Junior High School 3. Senior High School and above

16. Does this household own the following items with a minimum value of Rp 5,000,000 each?

a. Savings 1. Yes 3. No

b. Gold 1. Yes 3. No

c. Color TV 1. Yes 3. No

d. Livestock 1. Yes 3. No

e. Motorcycle 1. Yes 3. No

17. Are there toddlers (children between 0-4 years of age) in this household? 1. Yes, └─┴─┘persons 3. No


C2. Data Collection

1. Has this household been visited by PKPS BBM-SLT data collector? 1. Yes 3. No NO.7

2. How many data collector came? └─┴─┘persons 3. Who conducted the data collection? A. VILLAGE/KELURAHAN OFFICIALS E. STATISTICS OFFICERS/BPS OFFICERS/

B. PKK/POSYANDU CANDIDATES ENUMERATOR/BPS PARTNERS/ C. PUSKESMAS/MIDWIFE/PLKB OFFICERS PARTNER ASSISTANT D. INFORMAL LEADER V. OTHERS, ________________________ __

4. Did you recognize the data collector/s? (at least one) 1. Yes 3. No

5. During the visit, did you receive similar questions to the one we asked just now? 1. Yes 3. No

6. Did the data collector explain the purpose of the visit/data collection? 1. Yes 3. No

7. Does this household receive PKPS BBM-SLT [....]

a. First phase (for October-December 2005) 1. Yes 3. No

b. Second phase (for January-March 2006) 1. Yes 3. No

c. Third phase (for April-June 2006) 1. Yes 3. No 6. NON APPLICABLE

INTERVIEWER REMARKS: IF 7a, 7b and 7c = NO, CONTINUE TO NUMBER 9.

8. When the last time received the PKPS BBM-SLT fund, on whose behalf was it? (THE LAST TIME RESPONDENT RECEIVED PKPS BBM-SLT FUND)

a. Name : _______________________________________________________________________ b. HH member Number: └─┴─┘

9. If the respondent did not receive PKPS BBM-SLT in the last phase of PKPS BBM-SLT disbursement in this district/city, do you consider that your household should’ve received it?

1. Yes 3. No NO.11

10. For what reason? A. THIS HOUSEHOLD IS POOR B. ALL HOUSEHOLDS SHOULD RECEIVE THE MONEY V. OTHERS, _____________________________________________________________________

NO. 12

11. For what reason? A. THIS HOUSEHOLD IS NOT POOR B. THERE ARE OTHER HOUSEHOLDS MORE ENTITLED C. REFUSE ASSISTANCE V. OTHERS, _____________________________________________________________________

12. Do you know the requirement to get PKPS BBM-SLT? 1. Yes 3. No SECTIONI D


13. Where do you get the information? A. ELECTRONIC MEDIA (TV, RADIO) F. PUSKESMAS/MIDWIFE/PLKB OFFICER B. PRINTED MEDIA (NEWSPAPERS, TABLOID) G. PUBLIC FIGURE C. BROCHURE/BOARD/INFORMATION FLYERS H. STATISTICS OFFICER D. VILLAGE/KELURAHAN OFFICIALS V. OTHERS, __________________________ E. PKK/POSYANDU CADRE

14. Does the requirement precise/suitable? 1. Yes 3. No

15. In your opinion, does the people receive PKPS BBM-SLT in this village/kelurahan is truly eligible?

1. Yes SECTION D 3. No

16. In your opinion, who caused the inaccuracy? A. VILLAGE/KELURAHAN OFFICIALS E. STATISTICS OFFICERS /BPS OFFICERS B. PKK/POSYANDU CADRE ENUMERATOR/BPS PARTNERS/ C. PUSKESMAS/MIDWIFE/PLKB OFFICERS PARTNER ASSISTANT D. PUBLIC FIGURE V. OTHERS, __________________________

D. DISTRIBUTION OF FUEL SUBSIDY COMPENSATION CARD (KKB)

INTERVIEWER REMARKS: SECTION D & E ARE ESPECIALY FOR PKPS BBM-SLT RECIPIENTS HAVE YOU EVER RECEIVED SLT? (SEE ANSWER C2 NO. 7a/7b/7c)

1. YES 3. NO SECTION F

1. Who distributed the Fuel Subsidy Card?

A. VILLAGE/KELURAHAN OFFICIAL E. STATISTICS OFFICERS /BPS OFFICERS B. PKK/POSYANDU CADRE ENUMERATOR/BPS PARTNERS/ C. PUSKESMAS/MIDWIFE/PLKB OFFICERS PARTNER ASSISTANT D. PUBLIC FIGURE V. OTHERS, __________________________

2. How did you get the card? 1. DELIVERED TO RESIDENCE 3. IN A COMMUNITY MEETING 2. GO TO ___ (SEE ANSWER NO.1) 5. OTHERS, __________________________

3. Upon receiving the cards, were you informed about [...]:

a. The amount of money that suppose to be received in each withdrawal 1. Yes, Rp└─┴─┴─┘.└─┴─┴─┘ 3. No

b. The location to withdraw the money 1. Yes 3. No

c. Documents or cards that you must provide when you do withdrawal 1. Yes 3. No

d. Withdrawal schedule 1. Yes 3. No

e. Location to deliver complaint 1. Yes 3. No

4. Was there any cost that had to be paid to get the card? INTERVIEWER REMARKS: EXCLUDE RESPONDENT’S TRANSPORTATION COST TO THE

CARD DISTRIBUTION LOCATION.

1. Yes 3. No NO.8


5. How much did you have to pay the cost? Rp. └─┴─┴─┘.└─┴─┴─┘ 6. What was the payment for? 1. ADMINISTRATION COST 8. DO NOT KNOW

5. OTHERS, _____________________________

7. Who did you pay to? A. VILLAGE/KELURAHAN OFFICIAL E. STATISTICS OFFICERS/BPS OFFICERS/ B. PKK/POSYANDU CADRE ENUMERATOR/BPR PARTNERS/ C. PUSKESMAS/MIDWIFE/PLKB OFFICER PARTNER ASSISTANT D. PUBLIC FIGURE V. OTHERS, ________________________ __

8. As far as you know, is there any card that being postponed/canceled/withdrawn in this village/kelurahan?

1. Yes 3. No SECTION E 8. DO NOT KNOW SECTION E

9. What was the reason? E. DISBURSEMENT OF PKPS BBM-SLT MONEY AND ITS UTILIZATION INTERVIEWER REMARKS: QUESTIONS IN THIS SECTION REFER TO THE LATEST EXERIENCE OF RESPONDENT DURING DISBURSEMENT OF PKPS BBM-SLT FUND

1. Where did you withdraw PKPS BBM-SLT fund from? 1. POST OFFICE 5. OTHERS, __________________________

2. How far is the distance from your house? └─┘.└─┴─┴─┘meters 3. What transportation do you use to get to the location? A. On foot D. Car

B. Bicycle E. Boat C. Motorcycle V. Others, ___________________________

4. How much does the transportation cost? Rp. └─┴─┴─┘.└─┴─┴─┘ 5. Duration of the journey? └─┘.└─┴─┴─┘minutes 6. How much money do you receive? Rp. └─┴─┴─┘.└─┴─┴─┘ 7. Was there any cost to get the money? INTERVIEWER REMARKS: EXCLUDE RESPONDENT’S TRANSPORTATION COST TO THE

WITHDRAWAL LOCATION.

1. Yes 3. No NO.11

8. How much do you have to pay the cost? Rp. └─┴─┴─┘.└─┴─┴─┘ 9. What was the payment for? 1. ADMINISTRATION COST 8. DO NOT KNOW

5. OTHERS, _____________________________

10. Who did you pay to? A. VILLAGE/KELURAHAN OFFICIAL E. STATISTICS OFFICERS/BPS OFFICERS/ B. PKK/POSYANDU CADRE ENUMERATOR/BPS PARTNERS/ C. PUSKESMAS/MIDWIFE/PLKB OFFICER PARTNER ASSISTANT D. PUBLIC FIGURE V. OTHERS, ________________________ __

11. How long did you queue? └─┴─┴─┘minutes


12. How much was the last PKPS BBM-SLT and what did you spend it on?

a. Pay debt Rp. └─┴─┴─┘.└─┴─┴─┘ b. Buy rice Rp. └─┴─┴─┘.└─┴─┴─┘ c. Buy food Rp. └─┴─┴─┘.└─┴─┴─┘ d. Buy kerosene Rp. └─┴─┴─┘.└─┴─┴─┘ e. Buy gasoline Rp. └─┴─┴─┘.└─┴─┴─┘ f. Pay the school fees Rp. └─┴─┴─┘.└─┴─┴─┘ g. Buy medicine Rp. └─┴─┴─┘.└─┴─┴─┘ h. To add business capital Rp. └─┴─┴─┘.└─┴─┴─┘ i. Others,

___________________________________________________________________ Rp. └─┴─┴─┘.└─┴─┴─┘

j. Others, ___________________________________________________________________

Rp. └─┴─┴─┘.└─┴─┴─┘

k. Others, ___________________________________________________________________

Rp. └─┴─┴─┘.└─┴─┴─┘

13. How long was it until the money completely spent? └─┴─┘ days

14. Were there any people injured during queuing at the withdrawal location? 1. Yes 3. No

F. COMPLAINTS AND SUGGESTIONS

1. Do you have any complaint/problem regarding [...]?

a. Socialization of PKPS BBM-SLT 1. Yes, ________________________________ 3. No

b. Data collection of poor households receiving PKPS BBM-SLT 1. Yes, ________________________________ 3. No

c. Distribution of PKPS BBM-SLT cards 1. Yes, ________________________________ 3. No

d. Disbursement of PKPS BBM-SLT fund 1. Yes, ________________________________ 3. No

INTERVIEWER REMARKS: IF ALL ANSWERS OF NO.1 ARE (3) NO NO.8. IF ONE OF THE ANSWERS FROM NO.1 IS (1) YES, ASK NO.2

2. Have you ever delivered the complaints/problems?

1. Yes 3. No NO.6

3. Who did you deliver your complaint to? A. VILLAGE/KELURAHAN OFFICIAL E. STATISTICS OFFICERS/BPS OFFICERS/ B. PKK/POSYANDU CADRE ENUMERATOR/BPS PARTNERS/ C. PUSKESMAS/MIDWIFE/PLKB OFFICER PARTNER ASSISTANT


D. PUBLIC FIGURE V. OTHERS, ________________________ __

4. Are you satisfied with how they follow up your complaints/problems? 1. Yes NO.8 6. NOT APPLICABLE NO.8 3. No 8. DO NOT KNOW NO.8

5. Why not?

NO.8 6. Why you have never delivered any complaint/problem? A. NO MEDIA NO.8 D. ALREADY DELIVERED BY OTHERS

B. AFRAID V. OTHERS, __________________________ C. USELESS (RELUCTANT, HAVING ASSUMPTION THAT THERE WILL BE NO RESPONSE)

7. As far as you know, does the media to deliver complaints/problems available? 1. Yes 3. No 8. Has there been any [...], regarding the

implementation of PKPS BBM-SLT in this village/kelurahan?

9. What was the reason? 10. Did you or other HH member involved in [...]?

a. Public protests 1. Yes 3. No ↓ 1. Yes 3. No

b. Conflict/fights 1. Yes 3. No ↓ 1. Yes 3. No

c. Demonstrations 1. Yes 3. No ↓ 1. Yes 3. No

11. Do you have any suggestion to improve the implementation of PKPS BBM-SLT? 1. _____________________________________________________________________________ G. HOUSEHOLD INCOME AND SPENDING At the beginning of the interview, you have mentioned that the household member named _____, _____, _____ have been working/owned a job in the last 1 year (look at the Household Member Roster). We would like to ask the type of occupation and the income received from the occupation. G1. Income from Own-agriculture Occupation

1. During the last one year, have you or other HH member owned an independent agriculture occupation?

INTERVIEWER REMARKS: THE AGRICULTURE SECTOR INCLUDING FARM, CULTIVATED FIELD, SMALL SCALE ESTATE, SMALL SCALE LIVESTOCK FARM, AND SMALL SCALE POND/FISHPOND.


2. Plant/commodities 3. How many harvests in the last one year? 4. How much is the average income from

each harvest or each production? 5. How much is the total income in the last

one year? (NO.3 x NO. 4)

a.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


b.

└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

6. Total income from own-agriculture work Rp.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

G2. Income from Own-Non-agriculture Occupation

1. During the last 1 year, have you or other HH member owned an own-non-agriculture occupation (entrepreneurship)?


2. HH member Number

3. Main occupation in the last one year

4. Status of main occupation in the last one year

5. Average income monthly (from all income-generating occupation)

6. How many months of effective work in the last one year

7. Annual income (from all income-generating occupation)

[NO.5 x NO.6]

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 95 _______________________

1 2 3

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

8. Total income from own-non-agriculture work Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

INTERVIEWER REMARKS: SELECT ANSWERS FOR INCOME FROM OWN NON AGRICULTURAL OCCUPATION

3. Occupation Field 4. Occupation Status

1. Mining and Quarrying 6. Transportation and Communications 2. Manufacturing 7. Finance 3. Electricity, gas and water 8. Services 4. Construction 95. Others, ___________________ 5. Trade

1. Self-employed occupation (without help from permanent/temporary/paid/unpaid labor) 2. Occupation helped by temporary labor/unpaid labor 3. Occupation helped by permanent/paid labor


G3. Income from Salary/Wage

1. During the last 1year, have you or other HH member received salary/wage from working in a company or for other people?

1. Yes 3. No SECTIONG4

2.HH member number

3. Main occupation in the last 1 year

4. Status of the main occupation in the last 1 year

5. Average monthly income (from all occupations that generate salary/wage)

6. How many months of effective work in the last one year

7. Annual income (from all occupations that generate salary/wage)

[NO.5 x NO.6]

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

1 2 3 4 5 6 7 8 9 95 __________________________

1 2 3 4 5 _________________

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┘

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

8. Total income from salary/wage Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

INTERVIEWER REMARKS: CHOICES OF ANSWERS FOR INCOME FROM SALARY/WAGE

3. Main Occupation 4. Status of main occupation

1. Agriculture 6. Trade 2. Mining and Quarrying 7. Transportation and Communications 3. Manufacture 8. Finance 4. Electricity, gas and water 9. Services 5. Construction 95. Others, ____________________________

1. Civil servant 2. Private employee 3. Farm freelance workers 4. Non farm freelance workers 5. Others, _______________________________________________________________________

G4. Non-occupational income

1. During the last one year, have you or other HH member received non-occupational income, such as pension, grant, etc?


2. Income from […] in the last one year

a. Pension Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

b. Transfer/grant Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

c. Rent


Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

d. Interest Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

3. Total income in the last one year INTERVIEWER REMARKS: DO THIS CALCULATION TOGETHER WITH RESPONDENT TO

ENSURE ACCURACY OF THE RESPONDENT’S ANSWER.

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘ [NO. 2a + 2b + 2c + 2d]

G5. Household Spending

1. Average monthly spending for food consumption Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

2. Average monthly spending for non-food consumption (for example: school, water, electricity, transportation, health, social activity, house rent)

Rp.└─┴─┘.└─┴─┴─┘.└─┴─┴─┘

H. HOUSEHOLD ECONOMICS CONDITION

1. In general, how is the economic condition of this household compared to 2 years ago? 1. Improve 3. Deteriorate 2. The same 8. DO NOT KNOW

2. Why?

I NTERVIEWER REMARKS: NO.3 IS THE ENUMERATOR PERSONAL ASSESSMENT/OPINION. DO NOT ASK THIS QUESTION TO THE RESPONDENT! 3. BASED ON THE LOCAL STANDARD OF WELFARE, THIS HOUSEHOLD WELFARE CAN BE

CATEGORIZED AS:

1. VERY WEALTHY 4. POOR 2. WEALTHY 5. VERY POOR 3. MIDDLE CLASS





3. NUMBER THE MAIN RESPONDENTS IN ORDER (LOOK AT SECTION B HOUSEHOLD MEMBER ROSTER)

INTERVIEWER REMARKS: THE MAIN RESPONDENT IS THE MEMBER OF HOUSEHOLD WHO ANSWERS MOST OF THE QUESTIONS DURING THE INTERVIEW.

└─┴─┘





CONFIDENTIAL


S C H O O L P R I N C I P A L

School principal ID └─┴─┘└─┴─┘ 21 0└─┘

A. SCHOOL LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/Kelurahan *) Code └─┴─┴─┘ 5. School Name 6. Address 7. Postal Code └─┴─┴─┴─┴─┘ 8. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 9. Facsimile └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 10. Internet Website and/or Email Address (if available) *) Select One B. RESPONDENT IDENTITY

INTERVIEWER REMARKS: THIS QUESTION SHOULD ONLY BE ASKED TO THE RESPONDENT WHO IS NOT A SCHOOL PRINCIPAL, IF THE INFORMATION FOR THIS QUESTION HAS BEEN AVAILABLE BEFORE INTERVIEW, THIS QUESTION SHOULD NOT BE ASKED TO THE RESPONDENT. 0. If the School principal is not available, what is the reason for his/her absence?

1. External Assignment (meeting with the head of education dinas, participate in training, etc) 2. On leave (e.g.: vacation, maternal/paternal leave, etc.) 3. illness 5. Others, _______________________________________________________________________ 8. DO NOT KNOW

School Principal

1. What is your complete name? 2. What is your position? 1. School principal 3. Teacher (Senior)

2. Vice School principal

3. What is your employment status? 1. Civil Servant (PNS) 3. Non-Civil Servant NO. 5

4. What is your employment Rank? └─┴─┴─┘/└─┘ 5. Gender 1. Male 3. Female

6. What is your age at the moment? └─┴─┘ years

7. What is the highest level or degree of school you have completed? 1. Senior High School/Vocational/Islamic School 6. Diploma IV/Bachelor of Education Science 2. Diploma I/II Education Science 7. Diploma IV/Bachelor Non Education Science 3. Diploma I/II Non Education Science 8. Post Graduate (S2/S3) 4. Diploma III/Under Graduate Education Science 95. Others, ____________________________ 5. Diploma III/Under Graduate Non Education Science

8. Since when have you become _____ (SEE ANSWER NO.2) in this school? Month └─┴─┘ year └─┴─┴─┴─┘

9. Have you ever held school principal position in other schools? 1. Yes 3. No NO. 11

10. How long have you become a school principal in that place? (CONVERSE INTO MONTHS) └─┴─┴─┘ months 11. Since when have you been teaching? month └─┴─┘ year └─┴─┴─┴─┘ 12. Are you currently teaching? 1. Yes 3. No NO. 14

13. What subject do you teach? 14. In average, how many hours per day do you work in this school? └─┴─┘ hours per day 15. How far is the distance from your residence to this school? (IN METERS) └─┴─┘. └─┴─┴─┘ meters 16. What transportation do you normally use to get to this school? A. On foot D. Car

B. Bicycle E. Boat C. Motorcycle V. Others, __________________________

17. Do you work as a school principal in other place besides this school? 1. Yes 3. No C. GENERAL ASESSMENT OF THE SCHOOL CONDITION

1. Is the current [...] in this school sufficient?

a. Condition of the school building? 1. Yes 3. No

School Principal

b. Supporting facilities (library, laboratory, sports field, hall, toilets, etc) 1. Yes 3. No

c. Classroom appliences (desk and chair, blackboard, chalk, etc) 1. Yes 3. No

d. Supporting facilities for learning activities (books and other daily school needs, etc) 1. Yes 3. No

e. Number of teacher/teaching staff 1. Yes 3. No

f. Teacher/teaching staff quality 1. Yes 3. No

g. Student average score 1. Yes 3. No D. ESSENTIAL SCHOOL INFORMATION D1. School Vision and Mission

1. Who determines the vision and mission of the school? 1. Provincial Education Dinas 4. School principal and teachers SECTION D2 2. District/City Education Dinas 5. Principal, teachers & school committee SECTION D2 3. School principal SECTION D2 95. Others, ____________________________

INTERVIEWER REMARKS: ASK NO.2 IF THE SCHOOL PRINCIPAL DOES NOT DETERMINE THE VISION AND MISSION OF THE SCHOOL 2. Is the School principal involved in determining the vision and mission of the school?

1. Yes 3. No

D2. MBS (School-Based Management)

1. Has this school implemented MBS? 1. Yes 3. No NO. 5 8. DO NOT KNOW SEKSI D3

2. When was the MBS started to be implemented in this school? Month └─┴─┘ year └─┴─┴─┴─┘ 3. What problems did the school encounter in implementing MBS? A. NONE OR INADEQUATE TRAINING ON MBS

B. HAS NOT FULLY COMPREHEND MBS IMPLEMENTATION C. COMPLICATED BECAUSE IT REQUIRES COORDINATION WITH OTHER PARTIES V. OTHERS, _____________________________________________________________________

4. What positive benefits are felt from the implementation of MBS on the quality of education in this school?

A. IMPROVEMENT IN STUDENT’S SCORE D. NONE B. IMPROVEMENT IN STUDENT’S ATTENDANCE V. OTHERS, __________________________ C. IMPROVEMENT IN STUDENT’S DISCIPLINE Y. DO NOT KNOW

SECTIONI D3

5. Why is this school does not implement MBS? 1. DOES NOT KNOW THE MBS CONCEPT 3. DISAGREE WITH MBS CONCEPT 2. NOT YET PREPARED TO IMPLEMENT MBS 5. OTHERS,___________________________

School Principal

D3. RIPS (Rencana Induk Pengembangan Sekolah/Master Plan of School Development) and RAPBS (Rancangan Anggaran Pendapatan dan Belanja Sekolah/ School Budget)

1. Has the school prepared the RIPS for academic year 2005/2006? 1. Yes NO. 3 3. No

2. Why has it not prepared the RIPS? 3. Has the school prepared the RAPBS for the academic year 2005/2006? 1. Yes NO. 5 3. No

4. Why has it not prepared the RAPBS? SECTION D4

5. What was the RAPBS amount for academic year 2005/2006? Rp. └─┴─┴─┘.└─┴─┴─┘. └─┴─┴─┘

6. Who takes part in the preparation of RIPS and RAPBS? A. LOCAL EDUCATION DEPARTMENT (DINAS) D. SCHOOL COMMITTEE B. PRINCIPAL, TEACHERS AND E. COMMUNITY

SCHOOL EMPLOYEES C. PARENTS V. OTHERS, __________________________

D4. School Budget

1. Where did the school income for academic year 2005/2006 come from? A. STUDENT’S REGISTRATION FEE B. STUDENT’S TUITION FEE/COMMITTEE/BP3 FEE C. EXAMINATION FEE D. SCHOOL OPERATIONAL BUDGET FROM DISTRICT/CITY GOVERNMENT E. PROGRAM/AID FROM GOVERNMENT/PRIVATE SECTOR F. DONATION FROM COMMUNITY V. OTHERS, _____________________________________________________________________

2. School expenditure in academic year 2005/2006? A. BUILDING/CLASSROOMS/FACILITIES CONSTRUCTION B. BUILDING/CLASSROOMS/FACILITIES MAINTENANCE C. EDUCATION EQUIPMENT PROCUREMENT/MAINTENANCE D. BOOKS/LEARNING MATERIALS PROCUREMENT E. FREELANCE TEACHER’S SALARY F. TEACHERS’ INCENTIVE V. OTHERS, _____________________________________________________________________

D5. School Operational Aid (BOS)

1. Do you receive enough information regarding requirements, amount of funds and mechanism of School Operational Aid (BOS) program?

1. Yes 3. No NO.3

2. Where was the informastion received from? A. MASS MEDIA C. BRIEFING FROM EDUCATION DINAS

School Principal

B. LETTERS/FLYERS FROM EDUCATION DINAS

V. OTHERS, ___________________________

3. According to you, does the BOS socialization from the Education Dinas is enough? 1. Yes 3. No

4. Has this school received the BOS in academic year 2005/2006? 1. Yes 3. No NO. 2 8. DO NOT KNOW SECTION D6

5. How much was the BOS fund received by this school in academic year 2005/2006? Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 6. To present, how many times have the BOS funds disbursed? └─┘times

7. Does it in accordance with the amount that should be received? 1. Yes 3. No

8. Is there any ‘particular’ levy/expenses to ease the disbursement? 1. Yes, to_____________________________________________________________________ 3. No

9. What have been done to the disbursed funds? A. STUDENT REGISTRATION FORM MONEY F. TEACHER’S SALARY B. BOOK PROCUREMENT G. STUDENT’S ACTIVITIES C. SCHOOL EXAMINATION H. AID FOR POOR STUDENT D. STATIONERY V. OTHERS, __________________________ E. SMALL FACILITIES MAINTENANCE FEE

10. Was the amount of BOS funds in academic year 2005/2006 bigger than the RAPBS of academic year 2005/2006, or less?

1. Bigger 2. THE SAME 3. Less

11. Since this school receives BOS fund, what happen to the funds received from parents in academic year 2005/2006?

1. All of the funds were given back to parents 2. Partly returned to parents 3. Did not returned to parents 6. NOT APPLICABLE (DID NOT CHARGE PARENTS/COMMUNITY)

12. At present, how many [...] receives BOS in academic year 2005/2006?

a. Student └─┴─┴─┘ students

b. Poor Student └─┴─┴─┘ students

13. Does the school help the poor student with transportation cost? 1. Yes, └─┴─┴─┘ student 3. No NO.16

14. How does the transportation cost paid? 1. Once every 1 month 3. Once every 6 months 2. Once every 3 months 4. Once every 12 months

15. To whom does the transportation fund given? 1. Student 5. Others, ____________________________ 2. Parents

16. Does the BOS program have a positive impact on [...]?

a. Teaching quality of teachers 1. Yes 3. No

b. Books and teaching equipment availability 1. Yes 3. No

School Principal

c. School infrastructure 1. Yes 3. No

d. Access to school for poor students 1. Yes 3. No

17. With the BOS program, is there an increase in enrollment number of poor student to this school? 1. Yes 3. No

18. Whom do you report the utilization of BOS funds to? A. CENTRAL GOVERNMENT (DEPDIKNAS) D. INDEPENDENT MONITORING TEAM B. PROVINCIAL EDUCATION DINAS E. SUPERVISING AGENCY C. DISTRICT/CITY EDUCATION DINAS V. OTHERS, __________________________

19. Once in how many months do you have to deliver the BOS fund report? 1. Once a month 3. Once in six months 2. Once in three months 5. Others, ___________________________

20. What were the problems faced by this school related to BOS program? A. THERE WAS NO PROBLEM B. INSUFFICIENT SOCIALIZATION OF BOS PROGRAM C. OVERDUE DISBURSEMENT OF BOS FUNDS D. COMPLICATED PROCEDURES V. OTHERS, _____________________________________________________________________

21. What should be improved if the BOS program is to be continued? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

SECTION D6

12.Why is this school does not receive the BOS fund? A. DOES NOT AGREE WITH BOS PROGRAM B. DOES NOT NEED BOS PROGRAM, BECAUSE THE SCHOOL INCOME IS ENOUGH TO

COVER THE SCHOOL EXPENDITURE C. TOO LATE IN PREPARATION D. DOES NOT WANT TO BE OVERBURDENED BY COMPLICATED PROCEDURES AND

REPORTING SYSTEM V. OTHERS, _____________________________________________________________________

D6. Aid for Student from Poor Families INTERVIEWER REMARKS: SECTION D6 IS ONLY FOR SCHOOL THAT DOES NOT RECEIVE BOS PROGRAM

DID THIS SCHOOL RECEIVE THE BOS PROGRAM IN ACADEMIC YEAR 2005/2006? (SEE ANSWER OF SECTION D5 NO.4)

1. Yes SECTION D7 3. No

1. What is the percentage of student from poor families? (estimated) └─┴─┴─┘ percent (IF ANSWER IS ZERO SECTION D7)

School Principal

2. From all of the poor students, what is the percentage of poor student receiving aid from school in academic year 2005/2006/ (estimated) └─┴─┴─┘ percent (IF ANSWER IS ZERO SECTION D7)

3. What was the aid? A. RELIEF/WAIVER FROM ENROLLMENT/INITIAL FEE B. RELIEF/WAIVER FOR TUITION/BP3 FEE C. SCHOLARSHIPS D. FOSTER PARENTS FACILITIES V. OTHERS, _____________________________________________________________________

D7. Criteria for New Students Enrollment INTERVIEWER REMARKS: ONLY FOR ENROLLMENT OF NEW STUDENTS IN THE FIRST GRADE.

1. What was the main criteria to select the new student for new enrollment period of academic year 2005/2006?

1. School Final Examination (UAS) Score 2. National Final Examination (UAN) Score 3. Special test selection, level _______________________________________________________ 4. Amount of contribution 5. Age 6. Area Segmentation (Rayon) 95. Others, ______________________________________________________________________ 96. NOT APPLICABLE SECTION E

2. Who makes the final decision on the new student enrollment criteria? 1. Central Government (DepDikNas) 5. New Students Enrollment Committee 2. Provincial Education Dinas 6. School Committee 3. District/City Education Dinas 95. Others, ____________________________ 4. School principal 98. DO NOT KNOW

E. LEARNING ACTIVITIES E1. Curriculum

1. What curriculum was used in this school for academic year 2005/2006? A. 2004 CURRICULUM OR KBK (COMPETENCE-BASED CURRICULUM) B. 1999 CURRICULUM (REVISED VERSION OF THE 1994) C. 1994 CURRICULUM D. 1984 CURRICULUM V. OTHERS, ____________________________________________________________________

2. Who decided the implementation of the curriculum? 1. Provincial Education Dinas 4. School principal and teachers E2 2. District/City Education Dinas 5. Others, ____________________________

School Principal

3. School principal SECTION E2

INTERVIEWER REMARKS: ASK QUESTION NO.3 IF THE SCHOOL PRINCIPAL DOES NOT DECIDE CURRICULUM IMPLEMENTATION 3. Does the School principal involved in the decision making of curriculum?

1. Yes 3. No

E2. Main Reference Books

1. Who decide the main reference books to be used by student? 1. District/City Education Dinas 4. Teachers sole decision 2. School principal 5. Others, ____________________________ 3. Agreement between School principal and teachers

2. Does the school providemain reference books for teacher? 1. Yes 3. No

3. What efforts do you take if student cannot afford the main reference books?

E3. Others

1. If there is an absent teacher during his/her lesson, what shall the school principal do? 1. SEND THE STUDENTS HOME 2. GIVE THE STUDENTS ASSIGNMENTS TO WORK ON WITHOUT TEACHER SUPERVISION 3. ASSIGN OTHER TEACHER TO FILL IN FOR THE LESSON 4. FILL IN/TEACH DURING THAT LESSON 5. OTHERS, ____________________________________________________________________

F. TEACHERS F1. Number of Teachers

1. How many teachers are in this school? └─┴─┴─┘ persons 2. How many teachers are needed in this school? └─┴─┴─┘ persons F2. Principal and teachers meeting

1. Is there any regular meeting between the principal and teachers? 1. Yes 3. No SECTION F3

2. In the LAst 3 months, how many principal-teachers regular meetings were held? └─┴─┴─┘ times (IF THE ANSWER IS NONE NO.4)

3. What was the topic discussed in the meetings? A. NEW ADMINISTRATION PROCEDURES B. INTERACTION AND INPUT FROM SCHOOL COMMITTEE C. CURRICULUM

School Principal

D. PARTICULAR TEACHING METHOD E. STUDENTS DISCIPLINE F. EXAMINATION PREPARATION G. NEW STUDENTS ENROLLMENT H. FUTURE PLAN I. SCHOOL FEE V. OTHERS, ________________________________

4. Other than regular meeting, was there any other meeting (incidental) principal-teacher meeting? 1. Yes 3. No F3. Evaluation of Teacher’s Performance

1. Does the school Principal evaluate teacher’s performance? 1. Yes 3. No NO.3

2. What issues are evaluated? A. ABSENCE/ATTENDANCE B. TIME MANAGEMENT/PRECISION OF TEACHING HOURS C. TEACHING METHODS D. BEHAVIOR/MORALITY V. OTHERS, ____________________________________________________________________

3. What does the School principal do to the teacher with good performance? A. IGNORE B. PROVIDE COMPLIMENTS (ACKNOWLEDGEMENT) C. GIVE AWARDS D. FACILITATE THE PROMOTION PROCESS E. PRIORITIZE THE TEACHER TO PARTICIPATE IN THE CAPACITY BUILDING PROGRAMS V. OTHERS, _____________________________________________________________________

4. What does School principal do to the teacher with under-performance? A. IGNORE B. GIVE VERBAL REPRIMAND C. GIVE WRITTEN REPRIMAND D. POSTPONE THE PROMOTION PROCESS E. REPORT THE TEACHER TO THE DINAS TO BE FOLLOWED UP (e.g. MUTATION, ETC) V. OTHERS, _____________________________________________________________________

F4. Teacher’s Incentive

1. Are there incentives provided for the teachers for [...] activities in academic year 2005/2006?

a. Extracurricular 1. Yes 3. No 6. NOT APPLICABLE

b. Extra Lessons (courses) 1. Yes 3. No 6. NOT APPLICABLE

c. Involve in Committee 1. Yes 3. No 6. NOT APPLICABLE

School Principal

d. Examination Scoring 1. Yes 3. No 6. NOT APPLICABLE

e. Examination Supervision 1. Yes 3. No 6. NOT APPLICABLE

F5. Disciplinary actions for teachers

1. Has the Principal ever […]during academic year 2005/2006?


2. What caused the Principal to take that [...] action? A. FREQUENT LATENESS/EARLY LEAVE B. EXTENDED ABSENCE C. UNDER-PERFORM (e.g. POOR CLASS MANAGEMENT) D. STUDENT HARASHMENT E. INDECENT ROLE MODEL FOR STUDENT (DRUNK, SMOKING) F. FRAUD (LEAKING EXAMINATIONS , ETC) G. FINANCIAL CASE V. OTHERS,

_____________________________________________________________________

a. Give written reprimand to teacher 1 3 8 A B C D E F G V, ____________________________________________________________

b. Give verbal reprimand to the teacher

1 3 8 A B C D E F G V, ____________________________________________________________

c. Report violations to Dinas 1 3 8 A B C D E F G V, ____________________________________________________________

d. Propose mutation 1 3 8 A B C D E F G V, ____________________________________________________________ G. SCHOOL RELATIONSHIP WITH EXTERNAL PARTIES G1. Relationship with Education Dinas and Education Board (Dewan Pendidikan)

1. How many times did you attend oficial meeting held by the District/City Education Dinas or Branch of Subdistrict Education Dinas in the last 3 months? └─┴─┘ times (IF THE ANSWER IS NONE NO.3)

2. What was the topics discussed in the meeting? A. BOOKS PURCHASING G. PARTICULAR TEACHING METHODS B. FORMULATING SCHOOL BUDGET H. STUDENT DISCIPLINE C. NEW ADMINISTRATION PROCEDURES I. EXAMINATION PREPARATION D. TEACHER RECRUITMENT J. NEW STUDENTS ENROLLMENT E. LEARNING PROCESS K. FUTURE PLAN F. CURRICULUM V. OTHERS ___________________________

School Principal

3. How many time was [...] happen in the last 1 year? 4. When was [...] last conducted? a. Visit from the District/City Education Dinas or

Branch of Subdistrict Education Dinas (other than supervisor)

└─┴─┘ times Month └─┴─┘ year └─┴─┴─┴─┘

b. Visit from school supervisor └─┴─┘ times Month └─┴─┘ year └─┴─┴─┴─┘ c. Visit from Education └─┴─┘ times Month └─┴─┘ year └─┴─┴─┴─┘

5 Has the School principal sent [...] to the District/City Education Dinas or Branch of Subdistrict Education Dinas for the last 1 year?

a. Monthly report 1. Yes, __________________________________________________________________________ 3. No

b. Quarterly report 1. Yes, __________________________________________________________________________ 3. No

c. Semester report 1. Yes, __________________________________________________________________________ 3. No

d. Annual report 1. Yes, __________________________________________________________________________ 3. No

6. What actions were taken by the Education Dinas if the school does not send their report or submit the report late?

A. IGNORE B. INFORM THAT THE REPORT LATE/HAS NOT ARRIVED C. SEND REPRIMAND V. OTHERS, _____________________________________________________________________

7. Have you ever [...]to the District/City Education Dinas or Branch of Subdistrict Education Dinas in the Last 1 year?

8. How did you [...]? 9. In overall, did the Education Dinas’s give any response to your […]?

a. Submit proposal regarding school matters

1. Yes 3. No A. WRITTEN B. VERBAL V. OTHERS, _______________________

1. Yes, satisfactory 2. Yes, unsatisfactory 3. Has not responded

b. Report for problems related to school

1. Yes 3. No A. WRITTEN B. VERBAL V. OTHERS, _______________________

1. Yes, satisfactory 2. Yes, unsatisfactory 3. Did not respond

G2. School Committee Existance

1. Has this school established the school committee? 1. Yes 3. No NO. 3

School Principal

2. According to you, has the school committee played its roles and functions properly? INTERVIEWER REMARKS: A SCHOOL COMMITTEE HAS 4 ROLES (1) ADVISOR, (2)

SUPPORTER, (3) CONTROLLER AND (4) MEDIATOR.

1. Yes 3. No

SECTION G3

3. If the school committee has not yet established, does this school have plans to establish it? 1. Yes 3. No NO. 5

4. When do you plan to establish the school committee? Year └─┴─┴─┴─┘ SECTION G4 5. Why does this school have no plan to establish school committee? A. LIMITED HUMAN RESOURCES

B. POOR INTEREST OF THE COMMUNITY TO GET INVOLVED IN SCHOOL MANAGEMENT C. LIMITED CHANCE TO COLLECT IDEAS FROM THE COMMUNITY D. THE CURRENT INSTITUTION WITHIN THE SCHOOL IS STILL COMPATIBLE E. A SCHOOL COMMITTEE WOULD REDUCE SCHOOL AUTHORITY F. NO DEMAND/YET FROM THE COMMUNITY AND NEIGHBORHOOD G. NO POLITICAL SUPPORT FROM THE RELEVANT INSTITUTIONS H. SCHOOL COMMITTEE WOULD DELAY THE DECISION MAKING PROCESS IN SCHOOL I. SCHOOL COMMITTEE WOULD CREATE CONFLICT AMONG STAKEHOLDERS V. OTHERS, ________________________________________________________

SECTION G4

G3. Relationship with School Committee INTERVIEWER REMARKS: SECTION G3 IS ONLY FOR SCHOOLS WITH SCHOOL COMMITTEE

HAS A SCHOOL COMMITTEE ESTABLISHED IN THIS SCHOOL? (SEE ANSWER SECTION G2 NO.1)


1. Is there any particular meeting between Principal and the school commitee? 1. Yes, routine 2. Yes, irregular 3. No meeting (because school committe has just been established or inactive) NO.4

2. How many Principal-school committee meetings were held in the last one year? └─┴─┘ times 3. What was the topic that frequently discussed in the meeting? A. NEW ADMINISTRATION PROCEDURES F. STUDENTS DISCIPLINE

B. CURRICULUM G. EXAMINATION PREPARATION C. PARTICULAR TEACHING METHOD H. NEW STUDENTS ENROLLMENT D. FUND RAISING V. OTHERS, __________________________ E. SCHOOL FEE

4. According to you, does the school committee [...]?

a. Provide input for learning activities in this school 1. Yes 3. No 8. DO NOT KNOW

School Principal

b. Raising enough fund for school activities 1. Yes 3. No 8. DO NOT KNOW

c. Monitor the education and financial programs 1. Yes 3. No 8. DO NOT KNOW

d. Generally invite further involvment of the community/parents 1. Yes 3. No 8. DO NOT KNOW

G4. Relationship with Parents

1. When was the last parents meeting held? Month └─┴─┘ Year └─┴─┴─┴─┘ 2. Did the school give parents any chance to ask questions, deliver opinions, complains and

suggestions regarding learning process, facilities and school fee? 1. Yes 3. No, because ___________________________________________________ SECTION G5

3. How do they deliver the opinions, complaints and suggestions? A. DIRECTLY TO THE SCHOOL OR SCHOOL COMMITTEE B. SUGGESTION BOX IN SCHOOL OR GOVERNMENT OFFICE C. FORUM WITH VILLAGE GOVERNMENT D. FORUM WITH SUBDISTRICT GOVERNMENT E. FORUM WITH DISTRICT/CITY GOVERNMENT F. FORUM WITH PROVINCIAL GOVERNMENT G. MASS MEDIA H. NON GOVERNMENT ORGANIZATIONS (LSM) I. FORUM WITH RELIGIOUS INSTITUTION/LEADERS J. BUSINESS FORUM V. OTHERS, ____________________________________________________________________

4. What was the school response toward opinions, complaints and suggestions from parents? A. INVITE AND PROVIDE EXPLANATION TO PARENTS B. DISCUSS IN SCHOOL INTERNAL MEETINGS (TEACHERS AND PRINCIPAL) C. DISCUSS IN A MEETING WITH THE SCHOOL COMMITTEE D. DISCUSS IN A MEETING AMONG PARENTS, SCHOOL COMMITTEE, TEACHERS AND

PRINCIPAL E. IGNORE V. OTHERS, _____________________________________________________________________

G5. Relationship with Community

1. Has the principal ever attended meeting with community and/or village/kelurahan Government? INTERVIEWER REMARKS: MEETINGS INITIATED WHETHER BY THE PRINCIPAL OR

COMMUNITY AND/OR VILLAGE/KELURAHAN GOVERNMENT.


2. According to you, has the current community participation on the education is enough? 1. Yes 3. No 8. DO NOT KNOW G6. Information Dissemination

School Principal

1. To whom does the information on […] distributed? A. TEACHERS AND SCHOOL EMPLOYEES B. STUDENT C. PARENTS D. SCHOOL COMMITTEE E. COMMUNITY V. OTHERS, ________________________

2. What media is used to distribute the information of [...]? A. SCHOOL ANNOUNCEMENT BOARD B. VERBAL (SUCH AS MEETING) C. LETTER V. OTHERS

__________________________________________

a. School expenses that will be charged to parents A B C D E V, _____________________________________ A B C V, ___________________________________________

b. School program and activities A B C D E V, _____________________________________ A B C V, ___________________________________________

c. Donations/Aids received by the school A B C D E V, _____________________________________ A B C V, ___________________________________________

d. School condition, development and issues A B C D E V, _____________________________________ A B C V, ___________________________________________ H. INCOME INTERVIEWER REMARKS: THE FOLLOWING QUESTIONS REFER TO LAST MONTH’S INCOME OF RESPONDENTS.

1. How much was the income you received from this school last month?

a. Total Rp └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ b. Basic Salary Rp └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ c. Allowance Rp └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ d. Incentive Rp └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ e. Others Rp └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

2. Was your salary got deducted? 1. Yes 3. No NO.4 8. DO NOT KNOW NO.4

3. How much was the deduction? Rp └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 4. How was the salary paid? 1. Bank Transfer 4. Cash withdrawal in Education Dinas

2. Through Pos Office 5. Cash withdrawal in Local Government 3. Cash withdrawal from school treasury 95. Others, ____________________________

5. Was there any postpone/delay in last month’s salary payment? 1. Yes 3. No

6. Do you have any other occupation besides this school? 1. Yes 6. REFUSED TO ANSWER SECTION TLP 3. No SECTION TLP

7. What is the percentage of your income from this school compared to your total income last month? └─┴─┴─┘ percent

School Principal

TLP. RESPONDENT’S AVAILABLE PHONE NUMBER

a. House 1. Available: └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘, 3. Not Available 1. Phone Cell and/or House Phone

b. Phone Cell 1. Available: └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘, 3. Not Available BHS. LANGUAGE USED AND INFORMATION OF THE MAIN RESPONDENT

1. WHAT IS THE LANGUAGE MOST FREQUENTLY USED DURING THE INTERVIEW? 1. JAVA 7. MADURA 13. NIAS 19. LAMPUNG 2. SUNDA 8. SASAK 14. PALEMBANG 20. DAYAK 3. BALI 9. MINANG 15. SUMBAWA 21. INDONESIA 4. BATAK 10. BANJAR 16. TORAJA 95. OTHERS,________________ 5. BUGIS 11. BIMA 17. LAHAT 6. CHINESE 12. MAKASAR 18. BETAWI




School Principal



CONFIDENTIAL


T E A C H E R

Teacher ID └─┴─┘└─┴─┘ 22 └─┴─┘ A. SCHOOL LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/kelurahan *) Code └─┴─┴─┘ 5. School Name *) Select one B. RESPONDENT IDENTITY

1. What is your complete name? 2. What is your employment status? 1. Civil Servant 3. Non-Civil Servant NO. 4


5. What is your age at the moment? └─┴─┘ years 6. What is the highest level or degree of school you have completed? 1. Senior High School/Vocational/Islamic School 6. Diploma IV/Bachelor of Education Science

2. Diploma I/II Education Science 7. Diploma IV/Bachelor Non-Education Science 3. Diploma I/II Non-Education Science 8. Post Graduate (S2/S3) 4. Diploma III/Under Graduate Education Science 95. Others, ____________________________ 5. Diploma III/Under Graduate Non-Education Science

7. Since what year have you become a teacher? Month └─┴─┘ year └─┴─┴─┴─┘ 8. Since when have you become a teacher in this school? Year └─┴─┴─┴─┘

Teacher

9a. (QUESTION FOR ELEMENTARY SCHOOL TEACHER) What grade do you teach? 1. 5th grade 2. 6th grade NO. 10

9b. (QUESTION FOR JUNIOR HIGH SCHOOL TEACHER) What subject do you teach? 1. Indonesian language 2. Mathematics

10. How many hours do you teach in this school in 1 week? └─┴─┘ hours 11. How far is the distance from your residence to this school? (IN METERS) └─┴─┘. └─┴─┴─┘ meter 12. What transportation that you normally use to get to this school? A. On foot D. Car

B. Bicycle E. Boat C. Motorcycle V. Others,____________________

C. GENERAL ASESSMENT OF THE SCHOOL CONDITION

1. Is the current [...] in this school sufficient?

a. Condition of the school building 1. Yes 3. No

b. Supporting facilities (library, laboratory, sport facilities, hall, toilet, etc.) 1. Yes 3. No



e. Number of teachers 1. Yes 3. No

f. Teachers quality 1. Yes 3. No

g. Students average score 1. Yes 3. No

2. Specify 3 main problems you found as a teacher in this school? A. LOW SALARY B. IRREGULAR PAYMENT TIME (SALARY PAYMENT) C. UNCLEAR EMPLOYMENT STATUS D. INSUFFICIENT LONG TERM DEVICE AND INFRASTRUCTURE E. INSUFFICIENT TEACHING TOOLS (BOOKS, MAPS, ETC.) F. SPEND TOO MUCH TIME DOING NON-TEACHING ACTIVITIES G. HOUSING PROBLEM (RESIDENCE IS FAR FROM THE SCHOOL) H. INSUFFICIENCT TRANSPORTATION TO GET THE SCHOOL V1. OTHERS, _____________________________________________________________________ V2. OTHERS, _____________________________________________________________________ V3. OTHERS, _____________________________________________________________________

Teacher

D. LEARNING ACTIVITIES D1. Curriculum

1. What Curriculum do you use in teaching? A. 2004 CURRICULUM OR KBK (COMPETENCE-BASED CURRICULUM) B. 1999 CURRICULUM (REVISED VERSION OF THE 1994) C. 1994 CURRICULUM D. 1984 CURRICULUM V. OTHERS, ____________________________________________________________________

2. Who decided the implementation of the curriculum? 1. Provincial Education Dinas 4. Principal and Teacher 2. District/City Education Dinas 5. Others, ____________________________ 3. School Principal

3. Specify the obstacles you found in applying the curriculum? A. DOES NOT HAVE ENOUGH INFORMATION ON THE CURRICULUM B. ALREADY HAVE ENOUGH INFORMATION, BUT COULD NOT UNDERSTAND COMPLETELY C. HAVE NOT YET GOT THE APPROPRIATE TEACHING METHOD TO IMPLEMENT THE

CURRICULUM D. INSUFFICIENT TEACHING DEVICES, INFRASTRUCTURE AND DISPLAYS E. DIFFICULT FOR STUDENT TO UNDERSTAND THE TEACHING METHOD OF THE TEACHER V. OTHERS, _____________________________________________________________________ W. NOT APPLICABLE (DOES NOT ENCOUNTER ANY OBSTACLE)

D2. Teaching Method

1. Do you use [...] as a teaching method? 2. How many times in a month you use method [...]? (estimated)

1. Once a month 4. During every meeting 2. Once every 2 weeks 5. Others, ________________ 3. During most of the meetings

a. Led by Teacher (Instructor-led lectures) 1. Yes 3. No 1 2 3 4 5 _____________________________________

b. Class discussion 1. Yes 3. No 1 2 3 4 5 _____________________________________

c. Individual assignment 1. Yes 3. No 1 2 3 4 5 _____________________________________

d. Group assignment 1. Yes 3. No 1 2 3 4 5 _____________________________________

e. Experiment and/or field study 1. Yes 3. No 1 2 3 4 5 _____________________________________

3. Outside the classroom, what is the average time you consume per day for […] activity in the last 1 week?

a. Plan and prepare class lectures └─┴─┴─┘ minutes

Teacher

b. Examine daily tests and homework (PR) └─┴─┴─┘ minutes D3. Innovation/Breakthrough

1. Does the student pay attention when you teach? 1. Yes 3. No

2. Is there any specific method you applied to support a successful subject delivery to the students?

1. Yes 3. No SECTION D4

3. Please explain the method 1. ______________________________________________________________________________

4. How long have you applied the method? (CONVERT INTO MONTHS) └─┴─┘ months 5. Have the results proven yet? 1. Yes 3. Not yet SECTION D4

6. How? A. IMPROVEMENT OF STUDENT SCORE C. IMPROVEMENT OF STUDENT DISCIPLINE B. IMPROVEMENT OF STUDENT ATTENDANCE V. OTHERS, __________________________

D4. Use of Supporting Tools and Models

1. Do you use supporting tool or models in delivering your subject? 1. Yes NO. 3 3. No

2. Why? _________________________________________________________________________________ 3. Do you use models that allow the students to understand the lessons easier? 1. Yes SECTION D5 3. No

4. Why? D5. Main Reference

1. What is the main reference [...] you use?

a. Indonesian language Publisher__________________________________________________________________________ Publishing year└─┴─┴─┴─┘

b. Mathematics Publisher__________________________________________________________________________ Publishing year└─┴─┴─┴─┘

2. According to you, does the main reference suitable with the curriculum guidelines in this school? 1. Yes 3. No 8. DO NOT KNOW

3. Where did you get the main reference that being used at the moment? 1. From the School 3. Photocopy 2. Self-purchased 5. Others, ____________________________

4. Who decided the main reference manual you used? 1. Education Dinas 4. Self decision 2. Principal 5. Others, ____________________________ 3. Teacher Consensus

5. Do you also use additional books? 1. Yes 3. No

Teacher

6. Does your student use the main reference book? 1. Yes 3. No SECTION D6

7. Where does the student generally get the main reference book? 1. Free from school SECTION D6 5. Buy outside the school SECTION D6 2. Borrow from school 6. Copy SECTION D6 3. Purchase from school SECTION D6 95. Others, ____________________________ 4. Borrow from outside school SECTION D6

8. Does the student allowed to bring the books home? 1. Yes 3. No SECTION D6

9. For how long can the books brought home? 1. One semester 2. Until the subject taught have completely discussed 5. Others, _______________________________________________________________________

D6. Students Attendance INTERVIEWER REMARKS: SECTION D6 ONLY FOR PRIMARY TEACHERS.

IS THE RESPONDENT A ELEMENTARY SCHOOL TEACHER? 1. YES 3. NO SECTION D7

1. Do you always record student’s attendance on a daily basis? 1. Yes 3. No

2. What do you do when a student being absent for 3 days in a row without define information? A. ASK OTHER STUDENT REGARDING THE ABSENT STUDENT B. CONTACT/ WRITE LETTER TO HER/HIS PARENTS C. VISIT THE STUDENT’S HOUSE D. DOES NOT DO ANYTHING V. OTHERS, _____________________________________________________________________

D7. Teacher Activities outside the School Hours

1. Do you give courses outside school hours to […]?

a. Your own students 1. Yes 3. No

b. Students from other schools 1. Yes 3. No

INTERVIEWER REMARKS: ASK NUMBER 2 IF 1a = YES. ASK NUMBER 4 IF 1a AND 1b = NO. 2. Who initiate the course?

1. School initiative 3. Student initiative 2. Self initiative 5. Others, ____________________________

3. Do you receive payments for giving course to the student? 1. Yes 3. No

4. Does this school have extracurricular activities? 1. Yes 3. No SECTION E1

5. What are the extracurricular activities in this school? A. BOY SCOUTS D. COMPUTER G. SPORTS B. ARTS E. ENGLISH H. CADETS (PASKIBRA) C. SCHOOL DOCTOR (PMR) F. RELIGIOUS V. OTHERS, ___________

Teacher

6. Do you supervise either one of the activities? 1. Yes 3. No SECTION E1

7. What activity? A. BOY SCOUTS D. COMPUTER G. SPORTS B. ARTS E. ENGLISH H. CADETS (PASKIBRA) C. SCHOOL DOCTOR (PMR) F. RELIGIOUS V. OTHERS, ___________

8. Do you receive extra money/incentives for supervising the activity? 1. Yes 3. No E. RELATIONSHIP BETWEEN TEACHER AND SCHOOL PRINCIPAL, TEACHERS WORK GROUP (KKG) AND TEACHERS ASSEMBLY (MGMP), SCHOOL COMMITTEE, PARENTS AND EDUCATION

DINAS E1. School Principal and Teachers Meetings

1. Are there routine meetings between the Principal and teachers? 1. Yes 3. No SECTION E2

2. How often were routine Principal and teachers meeting held in the last 3 months? └─┴─┘ times 3. In the Principal and teachers meeting, did you deliver any proposal/suggestion/criticism? 1. Yes 3. No

E2. Meeting with Teachers’ Work Group (KKG for Elementary School) or Teachers Assembly (MGMP for Junior High School)

1. How many times do you participate in KKG/MGMP activities in the last 3 months? └─┴─┘ times (IF THE ANSWER IS ZERO SECTION E3) 2. What topics were discussed in the activity? A. CERTAIN TEACHING METHODS D. EXAMINATION PREPARATION

B. SUBJECT CURRICULUM E. FUTURE PLANS C. REFERENCE BOOK DETERMINATION V. OTHERS, __________________________

E3. Meeting with School Committee

1. Has this school established the school committee? 1. Yes 3. No SECTION E4

2. Are you a member of the school committee managerial structure? 1. Yes SECTION E4 3. No

3. How many times have you attended meetings with the school committee in the last 1 year? └─┴─┘ times (IF THE ANSWER IS ZERO NO.5) 4. What topics were discussed at the meetings? A. PARTICULAR TEACHING METHODS D. EXAMINATION PREPARATION

B. SUBJECT CURRICULUM E. FUTURE PLANS C. REFERENCE BOOK DETERMINATION V. OTHERS, __________________________

5. According to you, does the school committee […]?

a. Provide input on learning activities in class 1. Yes 3. No

b. Monitor the learning activity in class 1. Yes 3. No

Teacher

E4. Meeting with Parents

1. How many times have you meet (in person) with parents to discussed the student’s education progress during the last 6 months, apart from report card dissemination?

└─┴─┘ times (IF THE ANSWER IS ZERO SECTION E5)

2. Who initiate the meeting? 1. Teacher 2. Parents E5. Meetings with Education Dinas

1. How many times have you attended official meeting held by the district/city Education Dinas or subdistrict education branch office, in the last 1 year?

└─┴─┘ times (IF THE ANSWER IS ZERO NO.3)

2. What topics were discussed at the meeting? A. CERTAIN TEACHING METHODS D. EXAMINATION PREPARATION B. SUBJECT CURRICULUM E. FUTURE PLANS C. REFERENCE BOOK DETERMINATION V. OTHERS, __________________________

3. Have you ever [...] directly to district/city Education Dinas or subdistrict education branch office in the last 1 year?

4. How did you [...]? 5. In overall, did the dinas respond to your request/report?

a. Submit request 1. Yes 3. No ↓ A. WRITTEN B. VERBAL V. OTHERS, __________________

1. Yes, satisfactory 2. Yes, not satisfactory 3. Did not respond

b. Report problems 1. Yes 3. No ↓ A. WRITTEN B. VERBAL V. OTHERS, __________________

1. Yes, satisfactory 2. Yes, not satisfactory 3. Did not respond

F. TEACHER CAPACITY BUILDING

1. Is it easy for you to get information regarding education or capacity building activity for you as a teacher?

1. Yes 3. No

2. How many times have you participated in the capacity building activity in the last 1 year? └─┴─┘ times (IF ANSWER IS ZERO NO.6) 3. What was the type of activity you last participated in? 1. Training 4. Upgrading

2. Seminar 5. Others, ____________________________ 3. Workshop

4. When was the activity held? Month └─┴─┘ Year └─┴─┴─┴─┘ 5. Who organized the activity? 1. Department of National Education 4. Education Institution

2. Provincial Education Dinas 5. Non-education Institution 3. District Education Dinas 95. Others, ____________________________

6. Have you ever written articles/education essay? 1. Yes 3. No SECTION G

Teacher

7. When was the last time you wrote such articles/education essay? 1. This Month 4. In the last one year 2. Last Month 5. More than one year ago 3. In the last six months

G. INCOME INTERVIEWER REMARKS: THE FOLLOWING QUESTIONS REFER TO RESPONDENT’S INCOME OF LAST MONTH

1. How much was your income from this school, last month?

a. Total Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ b. Basic salary Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ c. Allowance Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ d. Incentive Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ e. Others Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

2. Was your salary got deducted? 1. Yes 3. No NO.4 8. DO NOT KNOW NO.4

3. How much was the deduction? Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 4. How was the salary paid? 1. Bank Transfer 4. Cash withdrawal in Education Dinas

2. Through Pos Office 5. Cash withdrawal in Local Government 3. Cash withdrawal from school treasury 95. Others, ____________________________

5. Was there any postpone/delay in last month’s salary payment? 1. Yes 3. No

6. Do you have any other occupation besides this school? 1. Yes 6. DECLINED TO ANSWER SECTION TLP 3. No SECTION TLP

7. What is the percentage of your income from this school compared to your total income last month?

└─┴─┴─┘ percent



b. Phone Cell 1. Available: └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘, 3. Not Available

Teacher








CONFIDENTIAL


S C H O O L C O M M I T T E E

School Committee ID └─┴─┘└─┴─┘ 23 0└─┘ A. SCHOOL LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/kelurahan *) Code └─┴─┴─┘ 5. School Name 6. Address *) Select One B. RESPONDENT IDENTITY

1. What is your complete name? 2. What is your position in the school committee? 1. Chairperson of School Committee

2. Deputy of School Committee 3. Member of School Committee

3. Since when did you act as ___ (SEE ANSWER NO.2) Month└─┴─┘ Year└─┴─┴─┴─┘ 4. Gender 1. Male 3. Female

5. What is your age at the moment? └─┴─┘ years 6. What is the highest level or degree of school you have completed? 1. Senior High School/Vocational/Islamic School 6. Diploma IV/Bachelor of Education Science

2. Diploma I/II Education Science 7. Diploma IV/Bachelor Non-Education Science 3. Diploma I/II Non-Education Science 8. Post Graduate (S2/S3) 4. Diploma III/Under Graduate Education Science 95. Others, ____________________________ 5. Diploma III/Under Graduate Non-Education Science

School Committee

C. THE SCHOOL COMMITTEE (KS) IDENTITY

1. How long is the working period of school committee (KS) in this school? └─┴─┘ years 2. Has this school committee had Article of Association (AD/ART)? 1. Yes 3. No 8. DO NOT KNOW

3. Does the school committee work scope only cover the interest of this school? 1. Yes 3. No 8. DO NOT KNOW

4. Does the member of school committee receive salary/incentive? 1. Yes 3. No NO. 7

5. How much is the salary/incentive per month? Rp └─┴─┴─┘.└─┴─┴─┘ 6. Where is the source of the salary/incentive? A. PARENTS COLLECTION V. OTHERS, __________________________

B. COMMITTEE OWN-SOURCE FUND Y. DO NOT KNOW

7. Does this school provide special room for school committee activities? 1. Yes 3. No 8. DO NOT KNOW

D. SCHOOL COMMITTEE ESTABLISHMENT PROCESS

1. Did the establishment of school committee initiated by establishment of a preliminary committee?

1. Yes 3. No NO. 6 8. DO NOT KNOW NO. 6

2. Did the preliminary committee held public socialization regarding school committee? 1. Yes 3. No NO. 4 8. DO NOT KNOW NO. 4

3. What was the media used to undertake the socialization? A. THROUGH A LETTER DESIGNATED TO PARENTS AND COMMUNITY B. THROUGH THE SCHOOL ANNOUNCEMENT BOARD C. INVITING PARENTS AND COMMUNITY TO A SCHOOL MEETING D. INFORMATION FLYERS E. PRINTED MEDIA/NEWSPAPERS F. ELECTRONIC MEDIA/TV/RADIO V. OTHERS, _____________________________________________________________________ Y. DO NOT KNOW

4. Did the preliminary committee make the list and select candidates for school committee members?


5. Did the preliminary committee facilitate the election of board and members of school committee by holding an establishment meeting?


6. How was the election process of the Chairperson and Deputy of School Committee? 1. Mutual agreement/discussion (Musyawarah) 4. Appointed by the Preliminary Committee 2. Voting 5. Others, ____________________________ 3. Appointed by the Principal

School Committee

E. SCHOOL COMMITTEE MEMBERSHIP

No. 1. Complete Name 2. Gender

1. Male 3.

Female

3. Position in School Committee?

1. Chairman 2. Deputy

Chairman 3. Secretary 4. Treasury 5. Member

4. Belong to which element? 1. Parents representative 2. Teachers 3. Community representative

/religious figures 4. Government representative 95. Others, ___________________

5. Daily occupation? 1. Civil Servant 2. Private Employee 3. Police/Military 4. Entrepreneur 5. Farmer 6. Factory labor (Buruh Pabrik) 7. Farm labor (Buruh Tani) 95. Others, ___________________


1. Have not go to school 2. Elementary School/SD/MI 3. Junior High School/SMP/MTs 4. High School/SMA/SMK/MA 5. Diploma I/II 6. Diploma III/Bachelor 7. Diploma IV/S1 8. Post Graduate (S2/S3) 95. Others, ___________________

1. 1 3 1 2 3 4 5 1 2 3 4 95 _________________ 1 2 3 4 5 6 7 95 _________ 1 2 3 4 5 6 7 8 95 _________

2. 1 3 1 2 3 4 5 1 2 3 4 95 _________________ 1 2 3 4 5 6 7 95 _________ 1 2 3 4 5 6 7 8 95 _________ F. GENERAL ASSESSMENT OF THE SCHOOL CONDITION Before having further discussion on school committee, we would like to ask for your opinion about the situation and/or condition of the school in which the school committee located.

1. According to your opinion, In general, is the current [...] in this school sufficient?

a. Condition of the school building 1. Yes 3. No

b. Supporting facilities (library, laboratory, sport facilities, hall, toilet, etc.) 1. Yes 3. No



e. Number of teachers 1. Yes 3. No

f. Teachers quality 1. Yes 3. No

g. Students average score 1. Yes 3. No

2. What is the most urgent problem that needs to be addressed/solved in this school? (BASED ON THE SELECTED ANSWER FOR NO.1, OR OTHER PROBLEM THAT

CONSIDERED TO BE IMPORTANT)

1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

School Committee

G. SCHOOL COMMITTEE ACTIVITIES

1. How many times did the school committee hold internal meetings in 2005? └─┴─┘ times 2. How many times did the school committee hold meetings with parents in 2005? └─┴─┘ times 3. How many times did the school committee hold meetings with Principal in 2005? └─┴─┘ times 4. What are the sources of funds for School Committee activities (such as meetings, etc)? A. PARENTS COLLECTION V. OTHERS, __________________________

B. COMMITTEE OWN-SOURCE FUNDS Y. DO NOT KNOW

5. Other than meetings, what are other activities of the school committee in the last one year?

6. What are/is the problem (s) you meet in running your tasks/functions as member/board of this school committee?

A. INSUFFICIENT SUPPORT FROM OTHER COMMITTEE MEMBERS B. INSUFFICIENT SUPPORT FROM PARENTS C. INSUFFICIENT COORDINATION WITH PRINCIPAL AND TEACHERS D. INSUFFICIENT SUPPORT FROM THE COMMUNITY V. OTHERS, _____________________________________________________________________ Y. DO NOT KNOW

H. THE ROLES OF SCHOOL COMMITTEE

We would like to know whether the school committee has performed its role related to school activities.

1. ADVISORY AGENCY

a. Does the school committee involved in school program determination? 1. Yes 3. No 8. DO NOT KNOW

b. Does the school committee involved in the attempt to improve teacher’s welfare? 1. Yes 3. No 8. DO NOT KNOW

c. Does the school committee involved in books and modeling tools procurement? 1. Yes 3. No 8. DO NOT KNOW

2. SUPPORT AGENCY

a. Does the school committee held fund raising activity from outside school (other than parent collection)?


b. Does the school committee collect the community social economic data and education resources within the community?


SCHOOL PHYSYCAL RENOVATION/IMPROVEMENT FUNCTION

c. Has there been any school physical renovation/improvement of during your working period in the school committee?

1. Yes 3. No NO. 3 8. DO NOT KNOW

d. Did the school committee being involved in school renovation/improvement monitoring?


e. Did the school committee provide in-kind support (non-financial)? 1. Yes 3. No 8. DO NOT KNOW

3. CONTROLLING AGENCY

School Committee

a. Does the school committee provide input on teaching and classroom learning process?


b. Has the school committee ever checked the school’s financial report? 1. Yes 3. No 8. DO NOT KNOW

c. Does the project or activity Official Order (SPK) in this school must be signed by the school committee?


4. AS MEDIATOR

a. Does the school committee receive suggestions, input, and complaints from the community and deliver them to the school?


b. Does the school committee organize meetings with government official, community figures to solve the school problems?


I. SCHOOL OPERATIONAL AID PROGRAM (BOS)

1. Did this school receive BOS program in academic year 2005/2005? 1. Yes 3. No NO. 12 8.DO NOT KNOW SECTION J

2. How much was the total amount of the BOS fund received by this school in that year? Rp └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. What have the BOS funds used for? A. OPERATIONAL COSTS RELATED TO THE REGISTRATION OF NEW STUDENTS

B. TEXT BOOKS AND REFERENCE BOOKS C. SCHOOL EXAMINATION COSTS AND STUDENT REPORT CARDS D. STATIONARY AND OTHER DAILY SCHOOL NEEDS E. SCHOOL REPAIRS AND MAINTENANCE F. REMUNERATION OF HONORARIUM TEACHERS G. STUDENTS ACTIVITIES H. AID FOR POOR STUDENTS V. OTHERS, _____________________________________________________________________

4. Was the BOS funds received in that year more? Or less than the school budget? 1. More 2. EQUAL 3. Less

5. Since this school receives BOS fund, what happen to the funds received from parents in academic year 2005/2006?

1. All of the funds were given back to parents 2. Partially given back to parents 3. Did not given back to parents 6. NOT APPLICABLE (DID NOT CHARGE PARENTS/COMMUNITY)

6. Currently, does the school waive all collection/donation/contribution from [...]

a. All students 1. Yes 3. No

b. Poor students 1. Yes 3. No

7. Does the school help the poor students with transportation expenses? 1. Yes 3. No

School Committee

8. Does the BOS program have a positive impact on [...]?

a. Teachers’ quality in teaching 1. Yes 3. No

b. Books and modelling tools availability 1. Yes 3. No

c. School infrastructure 1. Yes 3. No

d. Access to school for poor students 1. Yes 3. No

9. With BOS program, has there been any increase in number of poor students enrolled to this school?

1. Yes 3. No

10. What were the problems related to BOS program? A. NO PROBLEM B. INSUFFICIENT SOCIALIZATION OF BOS PROGRAM C. OVERDUE DISBURSEMENT OF BOS FUNDS D. COMPLICATED PROCEDURES V. OTHERS, _____________________________________________________________________

11. What should be improved if the BOS program is to be continued? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

SECTION J

12. Why didn’t this school receive BOS fund? A. DOES NOT AGREE WITH BOS PROGRAM B. DOES NOT NEED BOS PROGRAM, BECAUSE THE SCHOOL INCOME IS ENOUGH TO



J. AID FUNDS/PROGRAM

1. Has there any aid funds, apart from BOS, received by this school in academic year 2005/2006? 1. Yes 3. No SECTION BHS

2. Specify the programs. 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

School Committee








CONFIDENTIAL


S C H O O L S E C O N D A R Y D A T A

School Secondary Data ID └─┴─┘└─┴─┘ 24 0└─┘ A. SCHOOL LOCATION

1. Province _____________________________________________________ Code └─┴─┘ 2. District/City *) _____________________________________________________ Code └─┴─┘ 3. Subdistrict _____________________________________________________ Code └─┴─┴─┘ 4. Village/Kelurahan *) _____________________________________________________ Code └─┴─┴─┘ 5. School Name _________________________________________________________________________________ *) Select one B. RESPONDENT IDENTITY 1. What is your complete name? _________________________________________________________________________________ 2. What is your position? 1. Principal 3. Head of Employment Section

2. Head of Administration Section 5. Others, ____________________________

3. Gender? 1. Male 3. Female

4. What is your age? └─┴─┘ years 5. What is the highest level of education you have completed? 1. Senior high School/SMK/Islamic High (MA) 6. Diploma IV/S1 Vocational

2. Diploma I/II Vocational 7. Diploma IV/S1 Non-Vocational 3. Diploma I/II Non-Vocational 8. Post Graduate(S2/S3) 4. Diploma III/Bachelor of Vocational 95. Others, ____________________________ 5. Diploma III/Bachelor of Non-Vocational

School Secondary Data

C. GENERAL INFORMATION 1. School Statistic Number (NSS) └─┴─┘└─┘└─┴─┘└─┴─┘└─┴─┘└─┴─┴─┘ 2. School Identification Number (NIS) └─┴─┴─┴─┴─┴─┘ 3. When was this school established? (Year) └─┴─┴─┴─┘ 4. When was the last time this school renovated? (Year) └─┴─┴─┴─┘ 5. FOR PRIMARY SCHOOL IN PARTICULAR: School Cluster 1. Core 2. Spillover 3. Not yet participated D. LEARNING HOURS AND ADDITIONAL LEARNING HOURS

1. When is the learning activity conducted in this school? 1. Morning 2. Noon 3. Combination

School Learning Hours Additional Learning Hours Grade

2. Monday-Thursday 3. Friday 4. Saturday 5. Monday-Thursday 6. Friday 7. Saturday

1

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

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2

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3

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4

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

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└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

5

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

6

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘

└─┴─┘:└─┴─┘-└─┴─┘:└─┴─┘


E. STUDENT DATA E1. Number of Student and Classroom

Grade 1 Grade 2 Grade 3

Student Student Student

Academic Year

1. Male 2. Female

3. Classroom

4. Male 5. Female

6. Classroom

7. Male 8. Female

9. Classroom

a. 2003/2004 └─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

b. 2004/2005 └─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

c. 2005/2006 └─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

Grade 4 Grade 5 Grade 6

Student Student Student

Academic Year

10. Male 11. Female

12. Classroom

13. Male 14. Female

15. Classroom

16. Male 17. Female

18. Classroom

a. 2003/2004 └─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

b. 2004/2005 └─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

c. 2005/2006 └─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┘

E2. Failed and Dro-pout Student

Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Grade 6 How many student [...]?

1. L 2. P 3. L 4. P 5. L 6. P 7. L 8. P 9. L 10. P 11. L 12. P

a. Failed in academic year 2005/2006

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

b. Drop-out in academic year 2004/2005

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘


E3. Participation rate of School Final Exam (UAS) and National Exam (UAN) and Graduates of Academic Year 2004/2005

UAS Participants UAN Participants Graduates

1. Male 2. Female 3. Male 4. Female 5. Male 6. Female

└─┴─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┴─┘

└─┴─┴─┘

E4. School Final Exam (UAS) Score and National Exam (UAN) Score of Academic Year 2004/2005

UAS UAN Subjects

1. Minimum 2. Average 3. Maximum 4. Minimum 5. Average 6. Maximum

a. Bahasa Indonesia └─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

b. Mathematics └─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

c. English └─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

d. Total score └─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

└─┴─┘.└─┴─┘

e. Total subjects 7. └─┴─┘

8. └─┴─┘

E5. Examination Score for the New Students Enrollment of Academic Year 2005/2006

INTERVIEWER REMARKS: SECTION E5 IS ONLY FOR JUNIOR HIGH SCHOOL

IS THIS PRIMARY SCHOOL/JUNIOR HIGH SCHOOL? 1. PRIMARY SCHOOL SECTION E6 3. JUNIOR HIGH SCHOOL 1. What is the scoring used as the guideline to receive new students in this school? 1. National Exam 3. Selection Test

2. School Exam 6. NOT APPLICABLE

2. Total subjects └─┴─┘ 3. Minimum score └─┴─┘.└─┴─┘ 4. Average score └─┴─┘.└─┴─┘ 5. Maximum score └─┴─┘.└─┴─┘


E6. Scholarships in Academic Year 2005/2006

Scholarship 1. Number of scholarship recipients in academic year 2005/2006

2. How much is the average amount of the scholarship?

a. __________________________________________________

└─┴─┘ students

Rp. └─┴─┴─┘.└─┴─┴─┘ per student per month

b. __________________________________________________

└─┴─┘ students

Rp. └─┴─┴─┘.└─┴─┴─┘ per student per month

F. DATA ON SCHOOL’S FACILITY F1. School Reference Books

Teacher Textbook Student Textbook Subject

1. Total titles 2. Total books 3. Total titles 4. Total books

a. Bahasa Indonesia └─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

b. Mathematics └─┴─┘

└─┴─┴─┘

└─┴─┘

└─┴─┴─┘

F2. Number and Condition of the Classrooms

Possession Non Possession Type of Classrooms

1. Number in good condition 2.Number of slightly damaged 3. Number of severely damaged 4. Number

a. Classroom/ └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

b. Computer Room/Laboratory └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

c. Library └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

d. Multi function Room/School Hall └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

e. Student Health Unit (UKS) Room └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘


f. Counselling (BP/BK) Room └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

g. Principal Office └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

h. Teacher’s Office └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

i. Administrative Room └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

j. Teachers Toilet/Latrine └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

k. Student Toilet/Latrine └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

l. Sports Hall └─┴─┘

└─┴─┘

└─┴─┘

└─┴─┘

G. TEACHERS DATA

Teacher’s No.

1. Teacher’s Name (INCLUDING PRINCIPAL)

2.Gender 1. M 3. F

3. Age (yr)

4. Status of Employment

1.Local Civil Servant/PNS 2.Temporary GTT/Central Contract 3. Temporary GTT/Regional Contract 4. School GTT

5.Term of service as Teacher (all, in years)

6. What year you did you become teacher in this School

7. Highest education completed 1. High School (SMA)/Vocational/MA 2. Dipoma I/II Education Science 3. Diploma I/II Non Education Science 4. Diploma III/bacelor of Education Science 5. Diploma III/Bachelor of Non Education 6. Diploma IV/S1 Education 7. Diploma IV/S2 Non Education Science 8. Post Graduate (S2/S3) 95. Others,

__________________________

8. Subjects 9.Total working hours/ week

1.

1 3

└─┴─┘ 1 2 3 4

└─┴─┘

└─┴─┴─┴─┘

1 2 3 4 5 6 7 8 95 _______________________________

└─┴─┘

2.

1 3

└─┴─┘ 1 2 3 4

└─┴─┘

└─┴─┴─┴─┘

1 2 3 4 5 6 7 8 95 _______________________________

└─┴─┘

10. Is there any teachers who suppose to be on duty but in fact absent today? 1. Yes 3. No Section H


11. Please mention the teacher/s name INTERVIEWER REMARKS: RECORD THE NAME OF THE TEACHER, THEN WRITE

TEACHER’S NUMBER IN ACCORDANCE WITH THE TEACHER DETAILS ABOVE

12. The reason of today’s absencecy? 1. Performing other official assignment (meeting with dinas, participating in training, etc.) 2. Assigned by the Head of Education Dinas (as a bureaucrat) 3. On leave (for personal leave, vacation, maternal leave, etc.) 4. Sick/Illness 5. Others,

_______________________________________________________________________ 8. DO NOT KNOW

Teacher No. (SEE SECTION G)

Teacher/s Name

a. └─┴─┘ 1 2 3 4 5 _____________________________________________________ 8

b. └─┴─┘ 1 2 3 4 5 _____________________________________________________ 8

H. DETAILS OF COSTS THAT SHOULD BE PAID BY PARENTS FOR ACADEMIC YEAR 2005/2006

Students Contribution 1. Amount of contribution 2. Period: 1. Month 2. Semester 3. Academic Year 4. One Study Period

New Students

a. Registration fee (initial fee/enrollment fee, uniform expense etc.) Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

b. Compulsory fee (Tuition fee, POMG/BP3/school committee, etc.) Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

c. Semester examination fee Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

Final Grade Students

d. Re-registation fee Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

e. Compulsory fee (Tuition fee, POMG/BP3/school committee, etc.) Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4


f. Semester examination fee (Semester I Academic Year 2005/2006) Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

g. School/national examination fee (for Academic Year 2004/2005) Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

Miscellaneous

h. Extracurricular activities Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

i. Other routine expense, _______________________________________________________________

Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

j. Non-routine expense (study tour, recreation, etc.) Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 4

I. REALIZATION OF SCHOOL REVENUE AND EXPENDITURE

I1. School’s Routine Revenue INTERVIEWER REMARKS: REVENUE IS ALL REVENUE RECEIVED BY THE SCHOOL DURING 6 MONTHS IN 2005 (1 JULY – 31 DECEMBER 2005). ROUTINE CASH REVENUE IS CASH REVENUE WHICH HAS BEEN/WILL BE RECEIVED BY THE SCHOOL CONSECUTIVELY DURING 5 YEARS PERIOD.

1. Revenue 1a. Reception Code 2. Source of Revenue

3. Number of revenue Based on proof 4. Total final revenue

5.Source of total revenue 6. No. of attachments

a. ______________

1 2 3 4 5 6 95 1 2 5 _______

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

b. ______________

1 2 3 4 5 6 95 1 2 5 _______

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

c. ______________

1 2 3 4 5 6 95 1 2 5 _______

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘


Code I1.1a: 1. Registration fee 2. Initial fee 3. Tuition fee 4. Evaluation fee 5. Salary and incentive 6. Operational Cost 95. Others (NO NEED TO SPECIFY)

Code I1.2 1. Parents 2. Regional/National Budget 5. Others, specify: _____________

Code I1.5: 1. Based on proof 2. Based on self-calculation 3. Based on interview 5. Others, specify: ___________

I2. School Non-Routine Cash Revenue

INTERVIEWER REMARKS: CASH REVENUE IS REVENUE IN FORM OF CASH, RECEIVED BY THE SCHOOL DURING 6 MONTHS IN 2005 (1 JULY – 31 DECEMBER 2005). NON-ROUTINE CASH REVENUE IS CASH REVENUE RECEIVED BY THE SCHOOL NOT CONSECUTIVELY DURING THE PERIOD OF 5 YEARS.

1. Revenue 2. Source of revenue 3. Total revenue based on proof 4. Total final revenue 5. Source of total revenue

6. No. of attachment

a. _______________

1. Parents 2. Regional Budget/

National Budget 5. Others, _________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on self-calculation 3. Based on interview 5. Others, ___________

[ID] └─┴─┘

b. _______________

1. Parents 2. Regional Budget/

National Budget 5. Others, _________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on self-calculation 3. Based on interview 5. Others, ___________

[ID] └─┴─┘

7 . Cash balance as per 31 December 2004?

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ No. of Attachment: [ID] └─┴─┘

8. Cash balance as per 31 December 2005?


9. Cash balance as per 30 June 2005?



I3. Expenditures from School’s Routine Revenue INTERVIEWER REMARKS: ROUTINE EXPENDITURES IS THE EXPENDITURES INCURRED FROM ROUTINE CASH REVENUE FOR OPERATIONAL AND NON-OPERATIONAL ACTIVITIES DURING 6 MONTHS OF 2005 (1 JULY – 31 DECEMBER 2005).

1. Expenditures 2. Total expenditures based on proof 3. Final amount of expenditures 4. Source of total expenditures

5. No. of attachments

a. Teacher and school employees’ Salaries and incentives

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on calculation 3. Based on Interview 5. Others, ___________

[ID] └─┴─┘

b. Learning activities (KBM)

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘

c. Operational expenditure (non-KBM)

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘

d. _____________________________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘

I4. Expenditures from School Non-Routine Revenue INTERVIEWER REMARKS: NON ROUTINE EXPENDITURES IS THE EXPENDITURES FROM SCHOOL’S NON-ROUTINE REVENUE FOR OPERATIONAL AND NON OPERATIONAL ACTIVITIES DURING 6 MONTHS IN 2005 (1 JULY – 31 DECEMBER 2005).

1. Expenditures 2. Total expenditures based on proof 3. Final amount of expenditures 4. Source of total expenditures

5. No. of attachment

a. Teacher and scool employees’ Salaries and incentives

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘

b. learning activities (KBM) └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘


c. Operational expenditure (non-Learning Activities)

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘

d. ____________________________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


[ID] └─┴─┘

OL. DIRECT OBSERVATION OL1. SCHOOL CONDITION

1. IS THERE ANY ANNOUNCEMENT BOARD THAT DISPLAY VARIOUS INFORMATION? 1. YES 3. NO

2. HOW IS THE SCHOOL ENVIRONMENT CLEANLINESS? 1. CLEAN 2. DIRTY

OL2. CLASSROOM INTERVIEWER REMARKS: SD: GO TO ANY ROOM OF GRADE 4. IF THE NUMBER OF CLASSROOM FOR GRADE 4 IS MORE THAN 1, PLEASE GO TO THE SECOND CLASS, FOR EXAMPLE 4B OR 4-2. SMP: GO TO ANY ROOM OF GRADE 2. IF THE NUMBER OF CLASSROOM OF GRADE 2 IS MORE THAN 1, PLEASE GO TO THE SECOND CLASS, FOR EXAMPLE 2B OR 2-2

1. IS THERE ANY TEACHER DESK IN THIS CLASSROOM? 1. YES 3. NO

2. IS THERE ANY BLACKBOARD AND CHALK IN THIS CLASSROOM? 1. YES 3. NO

3. WHAT IS THE MAIN MATERIAL OF THE FLOOR 1. SOIL 2. NON-SOIL

4. HOW IS THE CONDITION OF THE FLOOR? 1. GOOD 2. SLIGHT DAMAGES 3. SEVERE DAMAGES

5. WHAT IS THE MAIN MATERIAL OF THE WALL? 1. CONCRETE 3. BAMBOO 2. WOOD 5. OTHERS, __________________________

6. HOW IS THE CONDITION OF THE WALL? 1. GOOD 2. MINOR DAMAGES 3. MAJOR DAMAGES

7. WHAT IS THE MAIN MATERIAL OF THE ROOF 1. CONCRETE 5. ASBESTOS 2. ROOF TILES 6. TATCH/PALM LEAF 3. SIRAP 95. OTHERS, __________________________ 4. ZINC

8. HOW IS THE CONDITION OF THE ROOF? 1. GOOD 2. SLIGHT DAMAGE 3. SEVERE DAMAGE


9. IS THERE ANY LIGHTING FACILITY THAT FUNCTION WELL? 1. YES 3. NO

10. WOULD THE CLASSROOM LEAK WHEN IT RAINS? 1. YES 3. NO

11. CLASSROOM ARRANGEMENT 1. CONVENTIONAL 2. CBSA (IN GROUPS)

12. DOES THE WORK OF THE STUDENT GOT DISPLAYED? 1. YES 3. NO

13. TOTAL STUDENT ENROLLED IN THIS CLASS └─┴─┘ STUDENTS 14. TOTAL STUDENT ATTEND THIS CLASS └─┴─┘ STUDENTS OL3. SCHOOL TOILET/LATRINE

1. IS THERE ANY TOILET/LATRINE FOR TEACHER? 1. YES 3. NO NO.4

2. HOW WAS THE CONDITION /SANITATION OF THE TOILET/LATRINE? 1. FUNCTIONING AND CLEAN 3. NOT FUNCTIONING /BROKEN 2. FUNCTIONING BUT DIRTY 8. DO NOT KNOW (LOCKED, ETC.) NO.4

3. IS THERE ENOUGH WATER IN THE TOILET? 1. YES 3. NO

4. IS THERE ANY SEPARATE TOILETS/LATRINE FOR STUDENT? 1. YES 3. NO SECTION OL4

5. HOW WAS THE CONDITION/SANITATION OF THE TOILET/LATRINE? 1. FUNCTIONING AND CLEAN 3. NOT FUNCTIONING /BROKEN 2. FUNCTIONING BUT DIRTY 8.DO NOT KNOW (LOCKED, ETC.) SECTION OL4

6. IS THERE ENOUGH WATER IN TOILET? 1. YES 3. NO

OL4. CONDITION OF THE ROAD AND TRANSPORTATION

1. DESCRIBE THE ROAD CONDITION THAT LEAD TO THIS SCHOOL _________________________________________________________________________________

2. TRANSPORTATION THAT COMMONLY USED TO GET TO THIS SCHOOL? A. ON FOOT D. CAR B. BICYCLE E. BOAT C. MOTORCYCLE V. OTHERS, __________________________

FK. HARD COPY

THE SCHOOL ANNUAL REPORT, THE CONDITION AS PER 31 AUGUST 2004 AND 31 AUGUST 2005 (LNS)


CP. INTERVIEWER NOTE

CP1. DIFFICULTIES WITH LICENSE/REGULATION, BOOKKEEPING REPORT AND OBJECT CLASIFICATION (SECTION M IN PARTICULAR) 1. DIFFICULTIES WITH

LICENSE OR REGULATION

________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________

2. DIFFICULTIES WITH REPORT OR BOOKKEEPING

________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________

3. DIFFICULTIES WITH OBJECT CLASIFICATION

________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________


CP2. INTERVIEWER NOTES


CONFIDENTIAL


E D U C A T I O N DINAS

EDUCATION DINAS ID └─┴─┘└─┴─┘ 26 01

A. LOCATION OF EDUCATION DINAS

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Official Name of Education Dinas 4. Address 5. Postal Code └─┴─┴─┴─┴─┘ 6. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 7. Fax └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 8. Internet sites and/or Email Address (if available) *) Select one

B. RESPONDENT IDENTITY INTERVIEWER REMARKS: IF INFORMATION FOR NO.1 AND 2 HAVE BEEN COLLECTED BEFORE THE INTERVIEW, THEY DO NOT NEED TO BE ASKED TO THE RESPONDENT.

1. What is your complete name? 2. What is your position? 1. Head of Education Dinas

2. Vice Head of Education Dinas 3. Head of Sub Dinas ______________________________________________________________

3. Since when did you act as _____ (SEE ANSWER TO NO.2)? Month└─┴─┘ Years ─┴─┴─┴─┘ 4. What was your job/position prior to the current position? 5. Gender 1. Male 3. Female

Education Dinas

6. What is your current age? └─┴─┘ years 7. What is the highest level of education you have completed? 1. Senior High School/Vocational/Islamic School 6. Diploma IV/Bachelor of Education Science

2. Diploma I/II Education Science 7. Diploma IV/Bachelor Non Education Science 3. Diploma I/II Non Education Science 8. Post Graduate (S2/S3) 4. Diploma III/Under Graduate Education Science 95. Others, ____________________________ 5. Diploma III/Under Graduate Non Education Science

C. GENERAL ASSESMENT TO THE EDUCATION SERVICE

1. At the moment, does this district/city have sufficient [...]?

a. Number of teachers/tutor 1. Yes 3. No

b. Teachers/tutors distribution 1. Yes 3. No

c. School equipment/infrastructure availability 1. Yes 3. No

d. Text books availability 1. Yes 3. No

e. Type and completeness of the information delivered by the school to Education Dinas regarding the school condition

1. Yes 3. No

f. School accessibility for public 1. Yes 3. No

g. People, parents and private sector participation in the education service (e.g. sharing thoughts provide materials/manpower)

1. Yes 3. No

D. AUTHORITIES

1. According to you, has there been a ‘tug-of-war’ of authorities between the district government and the provincial government?

1. Yes 3. No No.3

2. Please mention 3 main authorities that still being in dispute with the provincial government 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

3. Who has the ultimate authority to manage the education process of [...]?

a. SD/Elementary School 1. Depdiknas/Department of National Education 2. Provincial Dinas 3. District/city Dinas 5.Others, _________________

b. SMP/Junior High School 1. Depdiknas/Department of National Education 2. Provincial Dinas 3. District/city Dinas 5.others, _________________

4. Is there any decentralized authority that burdening the Education Dinas in this district/city? 1. Yes, namely____________________________________________________________________ 3. No SECTION E

Education Dinas

8. DO NOT KNOW SECTION E

5. Would it be best to return the authority to the province/central government? 1. Yes 3. No 8. DO NOT KNOW

E. PRIORITY ON THE DEVELOPMENT OF EDUCATION SECTOR

1. Does Education Dinas has a Dinas Strategic Plan/Renstra SKPD (Regional Government Work Unit)?

1. Yes 3. No

2. Does Education Dinas has a Unit Work Plan/Renja SKPD for 2006? 1. Yes 3. No

3. What are the 3 main priorities of the education sector policy in this district for fiscal year 2006? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

4. Is there any education program that targeting school-aged children from poor families? 1. Yes 3. No No. 6

5. What is the program? A. SCHOLARSHIP D. KEJAR PAKET A AND B (Basic Education for illiterate adult)

B. LOWER SCHOOL FEE V. OTHERS, __________________________ C. OPEN SCHOOL

6. Is there any health program that targeting people in remote/isolated areas? 1. Yes 3. No SECTION F 6. NOT APPLICABLE SECTION F

7. What is the program? A. SCHOLARSHIP D. KEJAR PAKET A AND B (Basic Education for illiterate adult)

B. LOWER SCHOOL FEE V. OTHERS, __________________________ C. OPEN SCHOOL

F. SCHOOL OPERATIONAL AID (BOS) We would like to discuss the BOS Program. There are 3 issues to be discussed namely (1) socialization, (2) implementation and (3) complaints media.

1. Was the BOS program socialization in this district/city sufficient? 1. Yes 3. No

2. What needs to be done to improve the socialization of BOS program? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

3. Is there any schools rejects the BOS program? 1. Yes 3. No No.5

4. What is the reason? A. DOES NOT AGREE WITH BOS PROGRAM B. DOES NOT NEED BOS PROGRAM, BECAUSE THE SCHOOL INCOME IS ENOUGH TO



Education Dinas

5. Has there been any problem in the implementation of BOS program in this district/city? 1. Yes 3. No No.8

6. What are the problems? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

7. How does Education Dinas overcome the problems? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

8. Each district/city is obliged to have a complaint channel/medium/institution related to BOS program. Has the complaint channels/media in this district/city appropriately functioned?

1. Yes 3. No 6. NOT APPLICABLE SECTION G

9. What are your suggestions to improve the complaint media? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

G. BUDGET FOR EDUCATION SECTOR G1. EDUCATION DINAS

1. Is the proposed draft of budget from the Education Dinas in RAPBD 2006 formulation process has based on the needs to provide optimum education service in this district/city?

1. Yes 3. No

2. Why?

3. In 2005, did the Education Dinas have [...] in the fund disbursement from the district/city government?

a. Deferral/delay 1. Yes 3. No

b. Deduction from APBD allocation 1. Yes 3. No

INTERVIEWER REMARKS: IF NO.3a OR 3b=YES. IF 3a AND 3b = NO, GO TO SECTION G2 4. What action was taken to overcome the delay or deduction in 2005?

A. PROPOSE ADDITIONAL BUDGET B. RE-ALLOCATE THE BUDGET IN THE DINAS C. NO ACTION WAS DONE, JUST SIMPLY USE THE EXIST FUNDS V. OTHERS, _____________________________________________________________________

5. Seeing this district/city’s financial capacity, does the 20 percent spending for education sector at the national/regional budget seems realistic?

INTERVIEWER REMARKS: STATE CONSTITUTION (UUD 1945) (ARTICLE 31 AMENDMENT 4) AND SISDIKNAS LAW (ARTICLE 49) SUGGEST THE CENTRAL GOVERNMENT AND DISTRICT /CITY GOVERNMENT SHOULD ALLOCATE AT LEAST 20 PERCENT OF THE APBN AND APBD BUDGET FOR EDUCATION SECTOR

1. Yes, because __________________________________________________________________ 3. No, because ___________________________________________________________________ 8. Do not know

6. What is the percentage of education budget of total 2006 APBD of this district/city? └─┴─┴─┘ percent

Education Dinas

G2. School

1. Is there any block grant or aid program, beside BOS, for [...] in AY 2005/2006?

2. Specify the name of the block grant or aid program.

3. Specify the source of the block grant or aid program.

a. Public Elementary School(SD) 1. Yes 3. No 8. DO NOT KNOW

a. ____________________________________

b. ____________________________________

c. ____________________________________

d. ____________________________________

e. ____________________________________

a. ____________________________________

b. ____________________________________

c. ____________________________________

d. ____________________________________

e. ____________________________________

b. Public Junior High School (SMP) 1. Yes 3. No 8. DO NOT KNOW

a. ____________________________________

b. ____________________________________

c. ____________________________________

d. ____________________________________

e. ____________________________________

a. ____________________________________

b. ____________________________________

c. ____________________________________

d. ____________________________________

e. ____________________________________

4. Does the budget allocation from the Education Dinas for school, in general, sufficient to cover the operational costs and maintenance of the school currently?

1. Yes SECTION H1 3. No

5. What would this district/city government do (through district/city Education Dinas) to meet the needs for budget?

A. PROPOSES MORE BUDGET IN APBD B. NO ACTION WOULD BE DONE V. OTHERS, _____________________________________________________________________ Y. DO NOT KNOW

Education Dinas

H. TEACHER H1. Decision Maker for Teacher Issue

1. Who finalize decision regarding […]?

1. Central Government/Department of National Education 2. District/City Education Dinas 3. Principal 5. Others, ___________________________________________

INTERVIEWER REMARKS: IF PRINCIPAL IS NOT THE FINAL DECISION MAKER: 2. Does the principal involved in the decision making process

regarding the issue?

a. Supporting teacher/honorary Recruitment 1 2 3 5 _______________________________________ 1. Yes 3. No

b. Participants of the teachers capacity building 1 2 3 5 _______________________________________ 1. Yes 3. No

c. Criteria to evaluate teachers’ performance 1 2 3 5 _______________________________________ 1. Yes 3. No H2. Teachers’ Capacity Building

1. Does the Education Dinas undertake teacher capacity building program in 2006? 1. Yes 3. No SECTION H3

2. What is/are type (s) of the capacity building program? A. DEVELOPMENTAL ASSIGNMENT /COLLEGE D. PROVIDE BOOKS/REFERENCE B. TRAINING V. OTHERS, __________________________ C. WORKSHOP/SEMINAR

H3. Teachers Performance

1. In 2005, was there any award for teacher with good performance? 1. Yes 3. No

2. In general, what was the weakness of teacher performance in 2005?

3. In 2006 does the dinas has any agenda/program to overcome the weakness? 1. Yes, ______________________________________________________________________ 3. No

H4. Miscellaneous

1. Does principal/teacher has the opportunity to innovate/experiment in the education service delivery?

1. Yes 3. No

2. What are the issues that are complained the most by the teachers to the Education Dinas in 2005? (in connection with the working relationship between the teachers and the Education Dinas)

A. SALARY E. EMPLOYMENT STATUS B. INCENTIVE V. OTHERS, __________________________ C. SCHOOL FACILITY W. NOT APPLICABLE (NO COMPLAINTS) D. LEARNING ACTIVITY SUPPORT FACILITY

Education Dinas

I. REFERENCE BOOKS

1. Who finalize decision regarding […]?

1. Central Government/Department of National Education 2. District/City Education Dinas 3. Principal 4. Teacher 5. Teachers Assembly (MGMP) 6. Principal Assembly(MKS) 95. Others, _________________________________________

INTERVIEWER REMARKS: IF PRINCIPAL IS NOT THE FINAL DECISION MAKER: 2. Does Principal involved in the decision making process

regarding the issue?

a. Reference books determination 1 2 3 4 5 6 95 _____________________________ 1. Yes 3. No

b. Reference books procurement 1 2 3 4 5 6 95 _____________________________ 1. Yes 3. No J. RELATIONSHIP WITH PROVINCE EDUCATION DINAS, EDUCATION BOARD, SCHOOL AND COMMUNITY/PUBLIC J1. Education Board

1. Is there any Education Board in this district/city? 1. Yes 3. No SECTION J2

2. Does the existence of the board contribute to the education service improvement in this district/city?

1. Yes 3. No

J2. School

1. Does Education Dinas evaluate the entire school’s performance in the last 1 year? 1. Yes 3. No No. 3

2. In general, based on the evaluation result, what are the main weaknesses of the school’s performance in this district/city?

3. Do all of the schools obliged to submit routine report to Education Dinas? 1. Yes 3. No SECTION J3

4. What is the type of the report? 1. Monthly Report, with the report format ____________________________________________ 2. Annual Report, with the report format _____________________________________________ 5. Others, _______________________________________________________________________

J3. Community/Public

1. Has the dinas ever received criticisms, complaints and suggestions from the community in regarding education service delivery in 2005?

1. Yes 3. No SECTION K

2. What were the issues that mostly raised? A. FACILITIES (SCHOOL CONDITION, CLEANLINESS, ETC) B. TOOLS FOR SCHOOL/LEARNING ACTIVITES AVAILABILITY C. TEACHER AVAILABILITY

Education Dinas

D. TEACHER MANNER E. SCHOOL REGISTRATION FEE F. SCHOOL TUITION FEE G. TOOLS AND SCHOOL ACTIVITIES’ COSTS V. OTHERS, _____________________________________________________________________

3. What was your response towards the complaints, criticisms and suggestions? A. ACCOMODATED THE COMPLAINTS/CRITICISM/SUGGESTION B. RESOLVED THE PROBLEM IMMEDIATELY, IF POSSIBLE C. DISCUSSED WITH RELEVANT STAFF/UNIT D. REPORTED TO DISTRICT HEAD/MAYOR E. DID NOT DO ANYTHING V. OTHERS, _____________________________________________________________________

K. TRANSPARENCY AND PARTICIPATION

1. Does Education Dinas actively publish/socialize program, budget and procedures of education service to the community?

1. Yes 3. No, because___________________________________________________________________

2. Can the community learn about, and/or access the public documents (work plan, budget, and policy) in Education Dinas?

1. Yes, by using ________________________________________________________________ 3. No, because ___________________________________________________________________

3. Does Education Dinas have any agenda to improve the education service transparency and participation in this district/city?

1. Yes, namely ____________________________________________________________________ 3. No, because ___________________________________________________________________

DS. SECONDARY DATA

1. How many employees work in the Education Dinas office in this district/city?

A. Civil Servant (PNS) └─┴─┴─┘ persons B. Non-Civil Servant (Non-PNS) └─┴─┴─┘ persons

2. How many [...] teachers with Civil servant status work in the Education Dinas office scope at the beginning of Academic Year of 2005/2006?

A. Elementary School (SD)/equal level └─┴─┴─┘ persons B. Junior High School (SMP)/equal level └─┴─┴─┘ persons

3. How many [...] students enrolled at the beginning of AY 2005/2006 (or in July 2005)? A. Elementary School (SD)/equal level └─┴─┘.└─┴─┴─┘students B. Junior High School (SMP)/equal level └─┴─┘.└─┴─┴─┘ students

Education Dinas

FK. HARD COPY

FOR SCHOOL THAT INCLUDED AS GDS-2 RESPONDENT:

1. SALARY AND INCENTIVE FOR THE TEACHERS FOR THE MONTHS JULY-DECEMBER 2005

2. SCHOOL BUDGET (APBS) 2005

3. ANNUAL REPORT (LNS) FOR 31 AUGUST 2004 AND FOR 31 AUGUST 2005






Education Dinas



CONFIDENTIAL


H E A D O F C O M M U N I T Y H E A L T H C E N T E R (P U S K E S M A S)

Head of Puskesmas ID └─┴─┘└─┴─┘ 31 0└─┘ A. LOCATION OF PUSKESMAS

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/kelurahan *) Code └─┴─┴─┘ 5. Puskesmas Name 6. Address 7. Postal Code └─┴─┴─┴─┴─┘ 8. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 9. Facsimile └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 10. Internet Website and/or Email Address (if available) *) Select one B. RESPONDENT IDENTITY

1. What is the name of the officer in charge for the (...) section?

a. Administration b. Patient Admission c. Women and Children Care (KIA) d. Dental Treatment e. Family Planning Service f. Tuberculosis Treatment

Head of Community Health Centre (Puskesmas)

g. Puskesmas Medicine Room/Storage h. Vaccine Room i. Laboratory j. Surveillance Officer

C. RESPONDENT IDENTITY

INTERVIEWER REMARKS: THIS QUESTION SHOULD ONLY BE ASKED FOR THE RESPONDENT WHO IS NOT THE HEAD OF THIS PUSKESMAS, IF THE INFORMATION FOR THIS QUESTION HAS BEEN AVAILABLE BEFORE INTERVIEW, THIS QUESTION SHOULD NOT BE ASKED TO THE RESPONDENT. 0. If Head of the Puskesmas is not available, what is the reason for her/his absence

1. On-duty visit to Pustu or Posyandu (Integrated Health Services) 2. Official assignment (meeting with Health Dinas, participate in training, etc.) 3. Bureaucratic assignment/representing head of Dinas (as Civil Servant) 4. Medical practice at private clinic/private practice 5. On Leave (such as: vacation, maternal leave, etc.) 6. Sick/illness 95. Others, _______________________________________________________________________ 98. DO NOT KNOW

1. What is your complete name? 2. What is your position? 1. Head of Puskesmas 5. Others, ____________________________

2. Senior Medical Doctor

3. What is your employment status? 1. Civil Servant 3. Non-civil servant NO. 5


6. What is your age at the moment? └─┴─┘ years 7. What is the highest level of education you have completed? 1. Senior High School/Vocational/Islamic High School (MA)

2. Diploma I/II 3. Diploma III/Under Graduate 4. Diploma IV/S1/Doctor 5. Post Graduate (S2/Specialist/S3/Super Specialist) 95. Others, _______________________________________________________________________

8. Since when have you become the _____ (SEE ANSWER NO.2) in this Puskesmas? Month └─┴─┘ Year └─┴─┴─┴─┘ 9. Have you ever held the Head of Puskesmas position in any other Puskesmas? 1. Yes 3. No NO. 11

10. How long have you become the head in that other Puskesmas? (CONVERT INTO MONTHS) └─┴─┴─┘ months 11. Since when have you worked in the health sector? Month └─┴─┘ Year └─┴─┴─┴─┘


INTERVIEWER REMARKS: THIS QUESTION SHOULD ONLY BE ASKED IF THE RESPONDENT IS A MEDICAL STAFF (DOCTOR, MIDWIFE, NURSE/PARAMEDIC) 12. Do you have a private practice other than this Puskesmas?

1. Yes 3. No NO. 14

13. How far is your private practice location from this Puskesmas? (CONVERT INTO METERS) INTERVIEWER REMARKS: IF THE RESPONDENT HAS MORE THAN ONE PRIVATE

PRACTICE LOCATIONS, ASK THE NEAREST ONE TO THE PUSKESMAS.

└─┴─┘.└─┴─┴─┘ meters

14. During the last week, how many hours did you spend on (.....) (ESTIMATED)

a. Activities in this Puskesmas └─┴─┘ hours b. Activities outside this Puskesmas but still related to your position as _____ (SEE

ANSWER NO. 2), such as attend meetings at the Health Dinas, attend seminars, etc.) └─┴─┘ hours

c. Field activities outside this Puskesmas but still related to your position as _____ (SEE ANSWER NO. 2), such as supervisory visits to Pustu, Posyandu (Integrated Health Services), etc.

└─┴─┘ hours

d. Other income generating activities and does not related to your position as _____ (SEE ANSWER NO. 2), such as private practice, etc.

└─┴─┘ hours

15. What is the percentage of your income from this Puskemas of the total income from all of your occupation during the last month?


16. Do you speak/understand the local dialect? 1. Yes 3. No D. HEALTHCARE SERVICE D1. Main Problems in Healthcare Service

1. Mention 3 main problems for the healthcare service in this Puskesmas INTERVIEWER REMARKS: WHAT WE WOULD LIKE TO FIND OUT ARE PROBLEMS IN

HEALTHCARE SERVICE, NOT THE COMMUNITY HEALTH PROBLEMS (SUCH AS THE WIDESPREAD OF A CONTAGIOUS DISEASES, ETC.)

A. LIMITED FACILITIES B. LIMITED MEDICAL OFFICER C. LIMITED MEDICINE AND VACCINE D. LIMITED MANAGERIAL CAPACITY E. REGIONAL POLICY DOES NOT COMPLETELY SUPPORT THE HEALTHCARE SERVICE VI. ___________________________________________________________________________ V2. ___________________________________________________________________________


D2. Reference for In-patient Care

1. Does this Puskesmas have in-patient care service? 1. Yes SECTION D3 3. No

2. If a patient requires in-patient care, where do you usually refer the patient to? 1. ___________________________________________________________________________ 2. ___________________________________________________________________________

3. Does this Puskesmas have a plan to self-upgrade to become a Puskesmas with in-patient care? 1. Yes 3. No

D3. Availability of Medicine, Vaccine, Contraception, Medical Supplies and Medical Equipment

1. Compared to the similar conditions 2 years ago, has the availability of (....) improved or deteriorated?

2. In 2005 did the Health Dinas constantly able to fulfill your requests for (....)?

3. In 2005, what did you do when the Health Dinas could not fulfill your requests of (...)?

a. Medicine 1. Improved 3. Deteriorated 2. THE SAME 6. NOT APPLICABLE

1. Yes 3. No, └─┴─┴─┘ percent

b. Vaccine 1. Improved 3. Deteriorated 2. THE SAME 6. NOT APPLICABLE

1. Yes 3. No, └─┴─┴─┘ percent

c. Contraception 1. Improved 3. Deteriorated 2. THE SAME 6. NOT APPLICABLE

1. Yes 3. No

d. Medical supplies 1. Improved 3. Deteriorated 2. THE SAME 6. NOT APPLICABLE

1. Yes 3. No

e. Medical equipment 1. Improved 3. Deteriorated 2. THE SAME 6. NOT APPLICABLE

1. Yes 3. No

D4. Healthcare Service Tariff

1. In providing healthcare services, how much is the tariff for (...)?

a. Admission/registration fee for out-patient care Rp. └─┴─┴─┘. └─┴─┴─┘ b. Out-patient care (first stadium, without medical treatment) Rp. └─┴─┴─┘. └─┴─┴─┘ c. Extraction/tooth filling (without complications) Rp. └─┴─┴─┘. └─┴─┴─┘ d. Medical Check Up for job application reference Rp. └─┴─┴─┘. └─┴─┴─┘ e. Blood Test (hematology) Rp. └─┴─┴─┘. └─┴─┴─┘

2. Who set the healthcare tariff in this Puskesmas? 1. Head of Puskesmas NO.5 2. Health Dinas 3. District/City Government with the Regional House of Representatives 5. Others, _______________________________________________________________________


3. Does the Head of the Puskesmas involved in setting the healthcare tariff? 1. Yes 3. No

4. Does the Head of the Puskesmas have the authority to adjust healthcare tariff according to this Puskesmas’ condition?

1. Yes 3. No NO.6

5. Does the Head of the Puskesmas inform the Health Dinas of the applicable tariff for healthcare services in this Puskesmas?

1. Yes 3. No

6. What policy regulates the tariff of the Puskesmas? 1. Head of Health Dinas Decree 5. Others, ____________________________ 2. LOCAL REGULATIONS (PERDA) 6. NOT APPLICABLE SECTION E

7. When was the policy for determination the current tariff in this Puskesmas issued? Month └─┴─┘ Year └─┴─┴─┴─┘ 8. Before that policy, what was the policy that being used? 1. Head of Health Dinas Decree 5. Others, ____________________________

2. LOCAL REGULATIONS (PERDA) 6. NOT APPLICABLE SECTION E

9. In what year did the policy issued? Year └─┴─┴─┴─┘

E. COMPENSATION FOR FUEL SUBSIDY REDUCTION – HEALTH SECTOR (PKPS BBM - BK)

1. Does the Head of Puskesmas involved in the selection of Health Insurance for the Poor (Askeskin) recipients?

1. Yes 3. No

2. Who involves in the selection? A. DISTRICT/CITY HEALTH DINAS OFFICIAL B. BKKBN (FAMILY PLANNING AGENCY) OFFICIAL C. PUSKESMAS OFFICIAL D. VILLAGE/HAMLET/RT GOVERNMENT APPARATUS V. OTHERS, _____________________________________________________________________ Y. DO NOT KNOW

3. What are the criteria to decide the candidate of Askeskin recipients? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

4. As far as you know, does the above criteria applied properly in the selection of household who receive Askeskin?

1. Yes 3. No

5. Who distributed the Askeskin cards? A. DISTRICT/CITY HEALTH DINAS OFFICIAL B. BKKBN (FAMILY PLANNING AGENCY) OFFICIAL C. PUSKESMAS OFFICIAL D. VILLAGE/HAMLET/RT GOVERNMENT APPARATUS V. OTHERS, _____________________________________________________________________

6. Have there been any patients who complain about the healthcare service delivery by using Askeskin in this Puskesmas? 1. Yes 3. No NO.10

7. To whom did the patients deliver the complaints? A. HEAD OF PUSKESMAS D. NURSE


B. MEDICAL DOCTOR V. OTHERS, __________________________ C. MIDWIFE

8. What was the patient’s complain about? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

9. What response has the Puskesmas usually give to patient’s complaints? A. PUT COMPLAINTS, CRITICISM AND SUGGESTIONS INTO RECORDS B. FOLLOW UP C. DELIVER IT TO THE HEALTH DINAS D. IGNORE V. OTHERS, _____________________________________________________________________

10. With the PKPS BBM-BK program, how many patients have been referred to hospital by using Askeskin, during 2005? (Estimated) └─┴─┴─┘ persons (IF ZERO NO.14)

11. Have been any Askeskin patients referred by the Puskesmas but then rejected by the hospital? 1. Yes 3. No NO.13

12. What was the reason?

13. Have there been any patients who complain about the service they received when using Askeskin in hospital?

1. Yes 3. No

14. What are the problems in the implementation of PKPS BBM-BK 2005 in this District/City? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

15. What are your suggestions to improve this PKPS BBM-BK? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

F. PUSKESMAS INTERNAL MANAGEMENT F1. Internal Meetings

1. Is there routine meeting between the Head of Puskesmas and the staff? 1. Yes 3. No SECTION F2

2. How many times have the meeting held in the last 3 months? └─┴─┴─┘ times (IF ZERO NO.4)

3. What were the topics discussed in the meetings?

A. LACK OF MEDICINE, VACCINE, CONTRACEPTION AND/OR MEDICAL SUPPLIES B. BUDGET INSUFFICIENCY/DELAY FROM THE HEALTH DINAS C. LACK OF MEDICAL WORKER D. EPIDEMIC V. OTHERS, _____________________________________________________________________

4. Other than the routine meetings, is there other meeting (incidental) between the Head of Puskesmas and the staff?

1. Yes 3. No


F2. Mechanism to Deliver Criticism, Complaints and Suggestion

1. Has the Hospital ever received criticism, complaints and suggestions from patients/public regarding the healthcare service delivery during the last 1 year?

1. Yes 3. No SECTION F3 8. DO NOT KNOW SECTION F3

2. How does patient/public deliver the complaints, criticism, suggestions regarding the healthcare service delivery?

A. DIRECTLY DELIVERED TO THE PUSKESMAS B. SUGGESTION BOX IN THE HOSPITAL OR GOVERNMENT OFFICE C. FORUM WITH VILLAGE/KELURAHAN OFFICIALS D. FORUM WITH SUB DISTRICT OFFICIALS E. FORUM WITH DISTRICT/CITY GOVERNMENT OFFICIALS F. FORUM WITH PROVINCIAL GOVERNMENT OFFICIALS G. MASS MEDIA (RADIO, TV, NEWSPAPERS, ETC.) H. FORUM WITH NON GOVERNMENT ORGANIZATION (NGO) I. FORUM/MEETING WITH COMMUNITY/RELIGIOUS LEADERS J. BUSINESS FORUM V. OTHERS, _____________________________________________________________________

3. What has been the most frequently delivered criticism, complaints and/or suggestions? A. CONDITION OF HEALTH FACILITIES (SPACE AVAILABILITY,CLEANLINESS,ETC.) B. MEDICINE, VACCINE, CONTRACEPTION AND/OR MEDICAL SUPPLIES AVAILABILITY C. HEALTHCARE STAFF MANNER D. HEALTHCARE SERVICE TARIFF E. HEALTHCARE SERVICE HOURS F. MISDIAGNOSIS/MISPRESCRIPTION OF MEDICINE/WRONG REFERRAL V. OTHERS _____________________________________________________________________

4. How does the Puskesmas response to the complaints, criticism and suggestion? A. PUT COMPLAINTS, CRITICISM AND SUGGESTIONS INTO RECORDS B. FOLLOW UP C. DELIVER IT TO THE HEALTH DINAS D. IGNORE V. OTHERS, _____________________________________________________________________

F3. Developmental Visits to Puskesmas Work Units

1. How many times the Puskesmas (Head of Puskesmas and/or other medical staff) visited (...) in the last 3 months?

2. Has this Puskesmas visited the entire (....) within its service area in the last 3 months?

a. Pustu (0. ) (96. NOT APPLICABLE ) └─┴─┘ (98. DO NOT KNOW )

1. Yes 8. DO NOT KNOW 3. No, because ___________________

b. Polindes (0. ) 1. Yes 8. DO NOT KNOW


(96. NOT APPLICABLE ) └─┴─┘ (98. DO NOT KNOW )

3. No, because ___________________

c. Mobile Puskesmas (0. ) (96. NOT APPLICABLE ) └─┴─┘ (98. DO NOT KNOW )

1. Yes 8. DO NOT KNOW 3. No, because ___________________

F4. Developmental Visits to Private Practices

1. Has the Puskesmas (Head of Puskesmas and/or other medical staff) visited (...) in the last 3 months?

a. General Medical Doctor 1. Yes, # visits └─┴─┘ 6. NOT APPLICABLE 3. No, because __________________________ 8. DO NOT KNOW

b. Maternity clinic with professional medical midwife 1. Yes, # visits └─┴─┘ 6. NOT APPLICABLE 3. No, because __________________________ 8. DO NOT KNOW

F5. Developmental Visits to Posyandu/Traditional Medical Practices

1. Has the Puskesmas (Head of Puskesmas and/or other medical staff) visited (....) in the last 3 months

a. Posyandu or Posyandu cadre 1. Yes, # visits └─┴─┘ 6. NOT APPLICABLE 3. No, because __________________________ 8. DO NOT KNOW

b. Traditional Medical Practices 1. Yes, # visits └─┴─┘ 6. NOT APPLICABLE 3. No, because __________________________ 8. DO NOT KNOW

G. PUSKESMAS EXTERNAL MANAGEMENT

G1. Meetings with Health Dinas

1. How many times have you attended official meetings held by the District/City Health Dinas in the last 1 month?

└─┴─┘times (IF ZERO SECTION G2)

2. What were the topics discussed in the meetings? A. PREPARATION OF HEALTHCARE PROGRAMS B. MEDICINE, VACCINE, CONTRACEPTION, MEDICAL SUPPLIES AND MEDICAL EQUIPMENT

PROCUREMENT C. DECISION OF HEALTHCARE TARIFF D. PREPARATION OF PUSKESMAS PROGRAMS F. HEALTHCARE BUDGET FORMULATION G. PUSKESMAS STAFF RECRUITMENT V. OTHERS, _____________________________________________________________________ Y. DO NOT KNOW


G2. Audit from Regional Audit Agency (Bawasda)

1. How many times has this Puskesmas received supervisory visits from the Bawasda in the last 1 year?

└─┴─┘times (IF ZERO SECTION G3)

2. When was the last time this Puskesmas (formally) received an auditing visit from Bawasda officer in the last 1 year?

Month └─┴─┘ Year └─┴─┴─┴─┘

3. How much time required by the Bawasda to perform the audit? └─┴─┘ days 4. Was there any prior notification from Bawasda about the visit? 1. Yes 3. No

5. How long was it take for the visit to happen after the notification was given? └─┴─┘ days 6 Did Bawasda inform the audit result to the Puskesmas? 1. Yes 3. No

G3. Supervisory Visit from Health Dinas

1. How many times has this Puskesmas received supervisory visits from the Health Dinas in the last 1 year?

└─┴─┘ times (IF ZERO SECTION G4)

2. To what issue was the supervision performed? A. IMPLEMENTATIUON OF ROUTINE BUDGET B. IMPLEMENTATION OF PROJECT/PROGRAM BUDGET C. PERFORMANCE IN PROJECT/PROGRAM IMPLEMENTATION V. OTHERS, _____________________________________________________________________

3. Did the Health Dinas inform the supervisory result to the Puskesmas? 1. Yes 3. No

G4. Report to the Health Dinas

1. What reports were sent to the District/City Health Dinas in the last 1 year?

a. Monthly report b. Annual report c. others

2. What action was taken by the Health Dinas if this Puskesmas does not/got late to send its report?

1. IGNORE B. INFORM THAT THE REPORT LATE/HAS NOT ARRIVED C. SEND NOTIFICATION/WARNING 5. OTHERS, _____________________________________________________________________

H. PUSKESMAS RETRIBUTION H1. Target of Retribution for Puskesmas Services

1. What is the retribution target for Puskesmas service for Fiscal Year 2005? Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


2. During 2005 how was the payment period? 1. Monthly 4. Annually 2. Quarterly 5. Others, ____________________________ 3. Semester

3. Was the retribution target for Fiscal Year 2005 met? 1. Yes 3. No

4. What is the retribution target for Puskesmas services for Fiscal Year 2006? Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ INTERVIEWER REMARKS: QUESTION NO.5 SHOULD ONLY BE ASKED IF THE RETRIBUTION TARGET FOR PUSKESMAS SERVICES FOR FY 2005 AND 2006 DIFFER (IF ANSWER NO 1 AND ANSWER NO 4 DIFFER). 5. Why there has been a change in retribution target for Puskesmas services?

1. ______________________________________________________________________________ 6. NOT APPLICABLE

H2. Share revenue/Retribution Return of Puskesmas

1. Is there any PERDA or Decree of Head of Dinas that regulates revenue sharing between the Puskesmas and the Health Dinas?

1. Yes, Local Regulation (PERDA ) No. ____________________________________________ 2. Yes, Head of Health Dinas Decree No. _______________________________________ 3. No

2. What is the percentage of shared revenue returned by the dinas? 1. └─┴─┴─┘percent 6. NOT APPLICABLE

3. In 2005, has there been any delay from the Health Dinas in returning shared revenue? 1. Yes 3. No NO.6

4. How long was the average payment delay of the shared revenue? └─┴─┘ months 5. What was the main reason for the delay?

6. Does the Puskesmas have the authority to decide the use of the shared revenue? 1. Yes 3. No

I. MINIMUM SERVICES STANDARD (SPM)

1. Does this District/City have a Minimum Services Standard (SPM) for the health sector? 1. Yes 3. No SECTION TLP

2. Was the Head of Puskesmas involved in the SPM formulation in this District/City? 1. Yes 3. No

3. Does the capacity of the Puskesmas (budget, human resources, facilities and infrastructure, information and technology) can meet the operation and achieve the SPM targets?

1. Yes 3. No

4. What efforts have been done by this Puskesmas to address this? A. REQUEST FOR ADDITIONAL BUDGET FROM THE HEALTH DINAS B. REQUEST THAT THE SPM TO BE RE EVALUATED V. OTHERS, _____________________________________________________________________

CONFIDENTIAL


PUSKESMAS SECONDARY DATA

ID Puskesmas Secondary data └─┴─┘└─┴─┘ 33 0└─┘ A. PUSKESMAS LOCATION

1. Province _____________________________________________________ Code └─┴─┘ 2. District/City *) _____________________________________________________ Code └─┴─┘ 3. Subdistrict _____________________________________________________ Code └─┴─┴─┘ 4. Village/Kelurahan *) _____________________________________________________ Code └─┴─┴─┘ 5. Puskesmas’ Name _________________________________________________________________________________ *) Select one B. ADMINISTRATION B1. Basic Information of Puskesmas

Data Source/Cross Check

1. The year the Puskesmas was established Year └─┴─┴─┴─┘ LT-1, Page 1, Section A, No.1

2. Service area of the Puskesmas

a. Service area scope └─┴─┴─┴─┘ km2 LT-1, Page 1, Section A, No.4.1

b. Population └─┴─┴─┘.└─┴─┴─┘ LT-1, Page 1, Section A, No.4.2

c. Number of head of household (KK) └─┴─┘.└─┴─┴─┘ HH LT-1, Page 1, Section A, No.4.3

d. Number of head of household with Health Card └─┴─┘.└─┴─┴─┘ HH Ask the administration official

e. Number of head of household who have JPS (Social Safety Net) Health Card └─┴─┘.└─┴─┴─┘ HH Ask the administration official

f. Number of head of household who have Askeskin (Health Insurance for the Poor) Card

└─┴─┘.└─┴─┴─┘ HH Ask the administration official

g. Number of Village/Kelurahan └─┴─┴─┘ LT-1, Page 1, Section A, No.4.5

3. Number of sub-Puskesmas (Pustu) └─┴─┘ LT-1, Page 2, Section A, No.9

Puskesmas Secondary Data

4. Number of Mobile Puskesmas (Pusling)/Floating Puskesmas └─┴─┘ LT-1, Page 3, Section B, No.27.1 and 27.2

5. Number of Village/District midwife └─┴─┘ Ask the administration official

6. Number of Integrated Health Post (Posyandu) └─┴─┘ LT-1, Page 4, Section C, No.41

7. Number of Village Maternity Post (Polindes) └─┴─┘ LT-1, Page 5, Section C, No.45

8. Number of Pesantren Health Post (Poskestren) └─┴─┘ LT-1, Page 5, Section C, No.49

9. Number of Village Medicine Post (POD) └─┴─┘ LT-1, Page 5 Section C, No.44

10. Is there any significant change in service area of Puskesmas, since the one reported in Section A, LT-1 in year 2005?

1. Yes 3. No

11. Is there any significant change in Puskesmas situation and infrastructure, since the one reported in Section B, LT-1 in 2005?

1. Yes 3. No

B2. Puskesmas Infrastructure Data

1. Which of these facilities mentioned below available at the Puskesmas? INTERVIEWER REMARKS: THE FACILITIES SHOULD EXIST AND STILL FUNCTION

PROPERLY.


a. Ambulance 1. Yes, └─┴─┘ unit 3. No Ask the administration official

c. Clean water facilities 1. Yes, 3. No LT-1, Page 3, Section B, No.28.1

d. Bathroom/toilet 1. Yes, └─┴─┘ unit 3. No Ask the administration official

e. Electricity 1. Yes, 3. No LT-1, Page 3, Section B, No.25

f. Electricity Generator 1. Yes, └─┴─┘ unit 3. No Ask the administration official

g. Computer 1. Yes, └─┴─┘ unit 3. No Ask the administration official

B3. List of Puskesmas’ Medical Staff and its Entire Link (Pustu, Polindes, Pusling, etc) THE STRATEGY TO GET THE INFORMATION FOR SECTION B3: 1. Copy of LT-2 (Staff Data Form) year 2005 2. Ask the rotation-medical staff that entered or left the Puskesmas after the report has been done 3. Cross the medical staff that already left. 4. Note down the information (No.1-6) from the medical staff who just enter. 5. For the new medical staff, ask questions No.7, 8 and 9.


No. 1. Name 2. Gender

. M

. F

3. Age (Year)

4. Type of Medical staff

1. General

Doctor/ Specialist

2. Dentist 3. Assistant

Dentist 4. Nurse/

Paramedic 5. Midwife

5. Highest level of education completed

1. High school

(SMA/SMK) 2. Diploma I/II 3. Diploma III /

Bachelor 4. Diploma

IV/S1/ Doctor 5. Postgraduate

work(S2/Specialist /S3/Super Specialist)

6. Status of employment

1. Civil Servant

(PNS) 2. PTT

(Temporary Staff)

5. Others, _______

7. What is the average weekly working hours at Puskesmas/Pustu/ Polindes in term of directly servicing the patient (examining patients)?

8. Do the staffs have their own practice besides the Puskesmas/ Pustu/Polindes?

1. Yes 3. No 8. DO NOT

KNOW

9. How far is the practice location from the Puskesmas/Pustu/Polindes?

0 At

Puskesmas/Pustu/Polindes or within its yard

1 < 1 km 2 1-5 km 3 6-10 km 4 > 10 km

1. 1 3 └─┴─┘

1 2 3 4 5 1 2 3 4 5 1 2 5 ____________

└─┴─┘ 1 3 8 0 1 2 3 4

2. 1 3 └─┴─┘

1 2 3 4 5 1 2 3 4 5 1 2 5 ____________

└─┴─┘ 1 3 8 0 1 2 3 4

3. 1 3 └─┴─┘

1 2 3 4 5 1 2 3 4 5 1 2 5 ____________

└─┴─┘ 1 3 8 0 1 2 3 4

C. PATIENT REGISTRATION

C1. Puskesmas Outpatient Service Hour

Day 1. Open 1 2. Close 1 3. Open 2 4. Close 2

a. Monday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ b. Tuesday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ c. Wednesday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ d. Thursday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ e. Friday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ f. Saturday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘


C2. Outpatient visit for the last one week.

Day 1. Date/Month 2. How many patients registered in registration book on [...]

0. None 996. Not applicable (Puskesmas was closed )

3. How many patients were using health card (JPS), Poor Insurance Card, Askeskin or other identity card referring that the patient came from poor family on day [...]

a. Monday └─┴─┘/└─┴─┘ └─┴─┴─┘ └─┴─┴─┘ b. Tuesday └─┴─┘/└─┴─┘ └─┴─┴─┘ └─┴─┴─┘ c. Wednesday └─┴─┘/└─┴─┘ └─┴─┴─┘ └─┴─┴─┘ d. Thursday └─┴─┘/└─┴─┘ └─┴─┴─┘ └─┴─┴─┘ e. Friday └─┴─┘/└─┴─┘ └─┴─┴─┘ └─┴─┴─┘ f. Saturday └─┴─┘/└─┴─┘ └─┴─┴─┘ └─┴─┴─┘

D. INPATIENT FACILITY INTERVIEWER REMARKS: SECTION D SHOULD ONLY BE ASKED TO PUSKESMAS WITH INPATIENT FACILITY.

DOES THE PUSKESMAS FACILITATED WITH IN PATIENT FACILITY? 1. YES 3. NO SECTION E


1. Number of bed for public treatment └─┴─┴─┘ beds LT-1, Page 1, Section A, No. 3.2, Line 3

2. Number of bed for laboring └─┴─┴─┘ beds LT-1, Page 1, Section A, No. 3.2, Line 4

3. The amount [...] 1 month ago

a. patients using inpatient facility └─┴─┴─┘ patients LB-4, Page 1, Section II, No. 1

b. Bed-days └─┴─┴─┘ bed-days LB-4, Page 1, Section II, No. 3

E. WOMEN AND CHILD CARE (KIA)

1. Does the Puskesmas provide the service [...]? INTERVIEWER’S POINTER: THE PUSKESMAS REFERED HERE SHOULD INCLUDE ALL

ITS LINK SUCH AS PUSTU, PUSLING, POLINDES ETC.

2. Number of patients received the service [...] in the last 1 month


a. K4 visit of Pregnant Women 1. Yes 3. No └─┴─┴─┘patient LB-3, Page 1, Section II, No.2

b. Birth Delivery 1. Yes 3. No Delivery attended by professional medical officer

└─┴─┴─┘ patient

LB-3. Page 1, Section II, No.6


F. DENTAL SERVICES 1. Does the Puskesmas provide the service [...]? INTERVIEWER’S POINTER: THE PUSKESMAS REFERED HERE SHOULD INCLUDE ALL




a. Extraction/tooth filling and other dental treatment

1. Yes 3. No └─┴─┴─┘patient LB-4, Page 1, Section IV, Adding from No. 1, 2 and 5

G. FAMILY PLANNING (KB) SERVICES

G1. Availability of KB Service

1. Does the Puskesmas provide the service [...]? INTERVIEWER’S POINTER: THE PUSKESMAS REFERED HERE SHOULD INCLUDE ITS

ENTIRE LINK SUCH AS PUSTU, PUSLING, POLINDES ETC.



a. Provision of Birth control Pill 1. Yes 3. No └─┴─┴─┘ patient Ask the official

b. Injectables birth control 1. Yes 3. No └─┴─┴─┘ patient Ask the official

c. Placement/Removal of the IUD 1. Yes 3. No └─┴─┴─┘ patient Ask the official

d. Family planning consultation 1. Yes 3. No └─┴─┴─┘ patient Ask the official

G2. Contraceptives Availability

Type of Contraception 1. At this moment, is the supply [...] available?

2. In the last 3 months, has Puskesmas ever run out of supply [...]?

3. For how many weeks was the Puskesmas run out of supply [...]?

a. Pill 1. Yes 3. No 1. Yes 3. No └─┴─┘ week b. Injection 1. Yes 3. No 1. Yes 3. No └─┴─┘ week c. Implant 1. Yes 3. No 1. Yes 3. No └─┴─┘ week d. IUD 1. Yes 3. No 1. Yes 3. No └─┴─┘ week e. Condom 1. Yes 3. No 1. Yes 3. No └─┴─┘ week

H. TB (Tuberculosis) SERVICES

1. Does the Puskesmas provide the service [...]? INTERVIEWER’S POINTER: THE PUSKESMAS REFERED HERE SHOULD INCLUDE ALL





a. Outpatient for TB 1. Yes 3. No └─┴─┴─┘ patient b. Inpatient for TB 1. Yes 3. No └─┴─┴─┘ patient

LB-3, Page 3, Section K --- there are several questions about TBC

I. PUSKESMAS MEDICINE ROOM/STORAGE

Type of Medicine 1. At this moment, is the supply [...] available?



a. Diarrhea Medicine, _________________

1. Yes 3. No 1. Yes 3. No └─┴─┘ week

b. Salt Liquid 1. Yes 3. No 1. Yes 3. No └─┴─┘ week c. Malaria Pill ______,

________________ 1. Yes 3. No 1. Yes 3. No └─┴─┘ week

d. Chloroquin (Klorokuin fosfat tab 250 mg)

1. Yes 3. No 1. Yes 3. No └─┴─┘ week

e. Sulfadoxin Pyrimethamine 1. Yes 3. No 1. Yes 3. No └─┴─┘ week f. Acute Respiratory Infection

Medicine (< 5 years), ___________

1. Yes 3. No 1. Yes 3. No └─┴─┘ week

g. Kotrimoksazol Syrup 1. Yes 3. No 1. Yes 3. No └─┴─┘ week h. Kotrimoksazol 480 mg 1. Yes 3. No 1. Yes 3. No └─┴─┘ week i. Paracetamol Syrup

(Acetaminophen) 1. Yes 3. No 1. Yes 3. No └─┴─┘ week

j. Tuberculosis Medicine, ______________

1. Yes 3. No 1. Yes 3. No └─┴─┘ week

k. Anti Tuberculosis (ATM) Category 1

1. Yes 3. N0 1. Yes 3. No └─┴─┘ week

l. Child ATM 1. Yes 3. No 1. Yes 3. No └─┴─┘ week m. Iron Pill 1. Yes 3. No 1. Yes 3. No └─┴─┘ week

J. VACCINE ROOM J1. Availability of Vaccination Service

1. Does Puskesmas provide vaccination service [...]? 2. Number of patients received the service [...] Data Source/Cross Check


INTERVIEWER’S POINTER: THE PUSKESMAS REFERED HERE SHOULD INCLUDE ITS ENTIRE LINK SUCH AS PUSTU, PUSLING, POLINDES ETC

in the last 1 month

a. DPT 3 1. Yes 3. No └─┴─┴─┘ patient Ask the official

b. Anti Polio 4 1. Yes 3. No └─┴─┴─┘ patient Ask the official

c. Tetanus toxoid 2 (for pregnant women)

1. Yes 3. No └─┴─┴─┘ patient LB-3, Page 2, Section I, No.6

d. Hepatitis B3 1. Yes 3. No └─┴─┴─┘ patient LB-3, Page 2, Section I, No.4

J2. Vaccine Availability

1. What vaccine storage facility is available at this Puskesmas? A. REFRIGERATOR/FREEZER/VACCINE COOLER BOX B. REGULAR REFRIGERATOR C. NO FACILITY V. OTHERS, _____________________________________________________________________

INTERVIEWER REMARKS: SEE THE RECAPITULATION OF IMUNIZATION RESULT AT PUSKESMAS OR GUIDELINE BOOK OF VACCINE STOCK

Type of vaccine and Injection Needle 1. At this moment, is the supply [...] available?



a. BCG 1. Yes 3. No 1. Yes 3. No └─┴─┘ week b. Anti Polio 1. Yes 3. No 1. Yes 3. No └─┴─┘ week c. Measles 1. Yes 3. No 1. Yes 3. No └─┴─┘ week d. Hepatitis B 1. Yes 3. No 1. Yes 3. No └─┴─┘ week e. Disposable needles 1. Yes 3. No 1. Yes 3. No └─┴─┘ week

K. LABORATORY SERVICES

1. Does Puskesmas provide vaccination service [...]? INTERVIEWER’S POINTER: THE PUSKESMAS REFERED HERE SHOULD INCLUDE ALL

ITS LINK SUCH AS PUSTU, PUSLING, POLINDES ETC



a. Sputum Examination 1. Yes 3. No └─┴─┴─┘ patient LB-4, Page 3, Section II, No.4

b. Blood Test (hematology) 1. Yes 3. No └─┴─┴─┘ patient LB-4, Page 3, Section II, No. 1


L. SURVEILLANCE ROOM/EPIDEMIC

INTERVIEWER REMARKS: ASK FOR REPORT OF W-1 DAN W-2

1. How many case of […] found in the last 1 month? a. TB (Tuberculosis) └─┴─┴─┘ case b. Malaria └─┴─┴─┘ case c. HIV └─┴─┴─┘ case d. Dengue fever └─┴─┴─┘ case e. Polio └─┴─┴─┘ case f. Malnutrition └─┴─┴─┘ case

M. REALIZATION OF PUSKESMAS’ REVENUE AND EXPENDITURE

M1. Puskesmas Routine Cash Revenue INTERVIEWER REMARKS: INCOME IS INCOME RECEIVED BY THE PUSKESMAS DURING 6 MONTHS IN 2005 (1 JULY – 31 DECEMBER 2005). ROUTINE CASH INCOME IS ALL THE CASH INCOME WHICH HAS/BEEN/WILL BE RECEIVED BY THE PUSKESMAS 5 YEARS CONSECUTIVELY.

1. Income 1a. Code 2. Income Source

3. Total Income based on proof 4. Final total Income

5. The source Final total Income

6. Attachment No.

a. ______________

1 2 3 4 5 1 2 3

5 ___________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

b. ______________

1 2 3 4 5 1 2 3

5 ___________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

c. ______________

1 2 3 4 5 1 2 3

5 ___________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘


1 Code.1a: 1. Retribution and service 2. Salary and incentive 3. Operational Fund 4. Askes (Govt. Health Insurance) Restitution 5. Others (Not need to be specified)

Code M1.2: 1. Patient 2. APBD/APBN (Govt. Budget) 3. ASKES 5. Others, specify: _____________

Code M1.5: 1. Based on proof 2. Based on calculation 3. Based on Interview 5. Others, specify: __________

M2. Puskesmas Non-Routine Cash Income

INTERVIEWER REMARKS: CASH REVENUE IS INCOME IN CASH FORM, RECEIVED BY THE PUSKESMAS DURING 6 MONTHS IN 2005 (1 JULY – 31 DECEMBER 2005). NON-ROUTINE CASH REVENUE IS CASH INCOME THAT CONSECUTIVELY RECEIVED BY THE PUSKESMAS IN 5 YEARS.

1. Income Description

2. Source 3. Total of Income based on proof 4. Final total Income

5. The source Final total Income

6. Attachment No.

a. _______________

1. Patient 2. APBD/APBN 3. ASKES 5. Others, ___________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on Calculation 3. Based on Interview 5. Others, specify:

____________________

[ID] └─┴─┘

b. _______________

1. Patient 2. APBD/APBN 3. ASKES 5. Others, ___________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on calculation 3. Based on interview 5. Others, specify:

____________________

[ID] └─┴─┘

7. Cash balance of Puskesmas as per 31 December 2004? └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ Attachment No. [ID] └─┴─┘

8. Cash balance of Puskesmas as per 31 December 2005? └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ Attachment No. [ID] └─┴─┘

9. Cash balance of Puskesmas as per 30 June 2005? └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ Attachment No. [ID] └─┴─┘ M3. Expenditure from Puskesmas Routine Revenue

INTERVIEWER REMARKS: ROUTINE EXPENDITURE IS EXPENDITURE OF THE PUSKESMAS’ ROUTINE CASH REVENUE FOR OPERATIONAL AND NON OPERATIONAL ACTIVITIES DURING 6 MOTNHS IN 2005 (1 JULY – 31 DECEMBER 2005).

1. Expenditures 2. Total Expenditure based on proof 3. Final total expenditures 4. The Source of final total expenditures

5. Attachment No.


a. Salary and incentive for medical and non medical staff └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

b. Operational service : 1. Medicine └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

2. Medical Equipment └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

3. Medical Equipment reparation └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

4. Contraceptives └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

5. Vaccine └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

6. Transportation └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

7. Others, _________________________ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

c. Non service Operational └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3s 5 ___________

[ID] └─┴─┘

d. ___________________________________ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

e. ___________________________________ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

Code M3.4 1. Based on proof 2. Based on Calculation 3. Based on Interview 5. Others, specify: ___________


M4. Puskesmas Expenditures from Non Routine Income INTERVIEWER REMARKS: NON ROUTINE EXPENDITURES IS EXPENDITURES FROM PUSKESMAS’S NON ROUTINE CASH REVENUE FOR OPERATIONAL AND NON OPERATIONAL ACTIVITIES DURING 2005 (1 JULY – 31 DECEMBER 2005).

1. Expenditures 2. Total Expenditures based on proof 3. Final total expenditures 4. Source of final total expenditures

5.Attachment No.

a. Salary and incentive for medical and non medical staff └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

b. Operational service: 1. Medicine └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

2. Medical Equipment └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

3. Medical Equipment reparation └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

4. Contraceptive └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

5. Vaccine └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

6. Transportation └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

7. Others, _________________________ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

c. Non service operational └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________

[ID] └─┴─┘

d. ___________________________________ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

e. ___________________________________ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1 2 3 5 ___________ [ID] └─┴─┘

Code M4.4 1. Based on proof 2. Based on calculation 3. Based on interview


5. Others, specify: ___________

M5. Goods Routine Revenue INTERVIEWER REMARKS: GOODS ROUTINE RECEIPT IS ALL GOODS REVENUE IN 6 MONTHS IN 2005 (1 JULY – 31 DECEMBER 2005) RECEIVED BY THE PUSKESMAS CONSECUTIVELY IN 5 YEARS

1. Income Description

2. Source 3. Total of Income based on proof 4. Final total Income 5. Source of final total income

6. Attachment No.

a. Medicine

A. Patient B. APBD/APBN C. ASKES V. Others, ___________

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on calculation 3. Based on interview 5. Others, specify :

____________________

[ID] └─┴─┘

b. Vaccine


└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on calculation 3. Based on interview 5. Others, specify :

[ID] └─┴─┘

c. Contraceptives


└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

1. Based on proof 2. Based on calculation 3. Based on interview 5. Others, specify:

____________________

[ID] └─┴─┘

OL. DIRECT OBSERVATION OL1. PATIENT WAITING ROOM INTERVIEWER REMARKS: IF THE PATIENT’S WAITING ROOM AND REGISTRATION ROOM ARE 2 SEPARATE ROOMS, THE OBSERVATION MUST BE DONE IN THE PATIENT’S WAITING ROOM

1. HOW MANY PATIENTS VISITED THE PUSKESMAS DURING OBSERVATION? └─┴─┘ PATIENTS TIME OF OBSERVATION └─┴─┘.└─┴─┘ 2. WAS THE ROOM CLOSED? 1. YES 3. NO

3. DID THE ROOM HAVE […]?

A. ADEQUATE LIGHTING 1. YES 3. NO

B. VENTILATION 1. YES 3. NO

C. GARBAGE CAN 1. YES 3. NO

D. BENCH/CHAIR 1. YES 3. NO


4. HOW WAS THE CONDITION OF THE FLOOR? A. CLEAN C.GOOD B. DIRTY (DUSTY, TRASH AND/OR GARBAGE) D . DAMAGED

5. HOW WAS THE CONDITION OF THE WALLS? A. CLEAN C. GOOD B. DIRTY (DUSTY, TRASH D. DAMAGED AND/OR GARBAGE)

INTERVIEWER REMARKS: ASK NO.6 IF IT IS NOT RAINING. 6. ON THE RAINY SEASON, DOES THE ROOM […]?

A. LEAKED 1. YES 3. NO

B. MUDDY 1. YES 3. NO

C. FLOODED 1. YES 3. NO

OL2. GENERAL POLYCLINIC EXAMINATION ROOM

1. DID THE ROOM HAS […]?

A. ENOUGH LIGHTING 1. YES 3. NO

B. VENTILATION 1. YES 3. NO

C. GARBAGE CAN 1. YES 3. NO

D. BENCH/CHAIR 1. YES 3. NO

4. HOW WAS THE CONDITION OF THE FLOOR? A. CLEAN C.GOOD B. DIRTY (DUSTY, TRASHY AND/OR GARBAGE) D. DAMAGED

5. HOW WAS THE CONDITION OF THE WALLS? A. CLEAN C. GOOD B. DIRTY (DUSTY,TRASH D. DAMAGED AND/OR GARBAGE)

4. HOW CLEAN WAS THE PARTITION CURTAIN IN THAT ROOM? 1. CLEAN 6. NOT APPLICABLE (THERE IS NO CURTAIN) 2. DIRTY (STAINED, ETC.)

5. WHAT WAS THE FACILITY TO WASH HANDS IN THAT ROOM? 1. SINK WITH CLEAN WATER 6. NOT APPLICABLE (THERE IS NO FACILITY) 2. CLEAN WATER BASIN

6. IS THERE EXAMINATION TABLE IN THAT ROOM? 1. YES 3. NO


OL3. BATHROOM/TOILET

1. WAS THERE ANY BATHROOM/TOILET FOR PATIENTS? 1. YES 3. NO SECTION N4

2. HOW WAS THE TOILET ‘S CONDITION? 1. FUNCTIONING AND CLEAN 3. NOT FUNCTIONING/OUT OF ORDER 2. FUNCTIONING BUT DIRTY 8. DO NOT KNOW (LOCKED, ETC) SECTION N4

3. WAS THERE ENOUGH WATER IN THE TOILET? 1. YES 3. NO

OL4. ROADS AND TRANSPORTATION

1. DESCRIBE THE ROAD CONDITION THAT GET TO THIS PUSKESMAS ____________________________________________________________________________________

2. TRANSPORTATION THAT COMMONLY USED TO GO TO THIS PUSKEMAS? A. ON FOOT D. CAR B. BICYCLE E. BOAT C. MOTORCYCLES V. OTHERS, __________________________

FK. HARD COPY

LT-1 YEAR 2005 CP. INTERVIEWER NOTE

CP1. DIFFICULTIES WITH LICENSE/REGULATION, BOOKKEEPING REPORT AND OBJECT CLASIFICATION (SECTION M IN PARTICULAR) 1. DIFFICULTIES WITH

LICENSE OR REGULATION

________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________

2. DIFFICULTIES WITH REPORT OR BOOKKEEPING

________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________


________________________________________________________________________________________________________________________________________ 3. DIFFICULTIES WITH

OBJECT CLASIFICATION ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________

CP2. INTERVIEWER NOTES


CONFIDENTIAL


H E A L T H DINAS

Health Dinas ID └─┴─┘└─┴─┘ 35 01 A. LOCATION OF HEALTH DINAS

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Official Name of the Health Dinas 4. Address 5. Postal Code └─┴─┴─┴─┴─┘ 6. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 7. Fax └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 8. Internet Sites and/or Email Address (if available) *) Select one B. RESPONDENT IDENTITY INTERVIEWER REMARKS: IF INFORMATION FOR NO.1 AND 2 HAVE BEEN COLLECTED BEFORE THE INTERVIEW, THEY DO NOT NEED TO BE ASKED TO THE RESPONDENT.

1. What is your complete name? 2. What is your position? 1. Head of Health Dinas

2. Vice of the Health Dinas 3. Head of Sub Dinas_______________________________________________________________

3. Since when did you act as _____ (SEE ANSWER NO.2)? Month └─┴─┘ year└─┴─┴─┴─┘ 4. What was your job/position prior to the current position? 5. Gender 1. Male 3. Female

6. What is your current age? └─┴─┘ years

Health Dinas

7. What is the highest level of education you have completed? 1. High School/Vocational/Islamic High School 4. Diploma IV/S1 2. Diploma I/II 5. Master/Doctor (S2/S3) 3. Diploma III/Bachelor 95. Others, ____________________________

C. PERCEPTION ON HEALTH SERVICE We would like to ask your opinion on the Healthcare services in this district/city.

1. At the moment, does this district/city have sufficient [...]?

a. Doctor availability 1. Yes 3. No

b. Midwife availability 1. Yes 3. No

c. Nurse availability 1. Yes 3. No

d. Medicine availability 1. Yes 3. No

e. Vaccine availability 1. Yes 3. No

f. Medical supplies availability 1. Yes 3. No

g. Medical equipment availability 1. Yes 3. No

h. People access to Puskesmas 1. Yes 3. No

i. People access to Public Hospital 1. Yes 3. No D. AUTHORITIES

1. According to you, has there been a ‘tug-of-war’ of authorities between the district government and the provincial government?

1. Yes 3. No NO.3


3. Is there any decentralized authority in health that burdening the Health Dinas in this district/city? 1. Yes, namely ____________________________________________________________________ 3. No SECTION E 8. DO NOT KNOW SECTION E

4. Would it be best to return the authority to the province/central government? 1. Yes 3. No 8. DO NOT KNOW E. PRIORITY ON THE DEVELOPMENT OF THE HEALTH SECTOR

1. Does the Health Dinas has a Dinas Strategic Plan/Renstra SKPD (Local Government Working Unit)?

1. Yes 3. No

2. Does the Health Dinas has a Unit Work Plan/Renja SKPD 2006? 1. Yes 3. No

Health Dinas

3. What are the 3 main priorities of the health sector policy in this district for fiscal year 2006? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

4. Is there any health program that targeting poor family? 1. Yes 3. No NO.6

5. What is the program? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

6. Is there any health program that targeting people in remote/isolated areas? 1. Yes 3. No SECTION F 6. NOT APPLICABLE SECTION F

7. What is the program? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

F. COMPENSATION PROGRAM TO REDUCE FUEL SUBSIDY ON HEALTH SECTOR (PKPS BBM–BK) We will discuss PKPS BBM-BK. Three issues to be discussed are (1) socialization, (2) implementation and (3) complaint media .

1. Was the socialization of PKPS BBM-BK in this district/city sufficient? 1. Yes 3. No

2. What needs to be done to improve the socialization of PKPS BBM-BK? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

3. Has there been any problem in the implementation of PKPS BBM-BK in this district/city? 1. Yes 3. No NO.6

4. What are the problems? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

5. How does Health Dinas overcome the problems? 1. ______________________________________________________________________________

6. Each district/city is obliged to have a complaint channel/medium/institution related to PKPS BBM Health Sector. Has the complaint channels/media in this district/city appropriately functioned?

1. Yes 3. No 6. NOT APPLICABLE SECTION G

7. What are your suggestions to improve the complaint media? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________

G. BUDGET FOR PUBLIC HEALTH SERVICES G1. Health Dinas

1. Is the proposed draft of budget from the Health Dinas in RAPBD 2006 formulation process has based on the needs to provide optimum medical service in this district/city?

1. Yes 3. No

2. Why?

Health Dinas

3. In 2005, did the Health Dinas have [...] in the fund disbursement from the district/city government?

a. Deferral/delay 1. Yes 3. No

b. Deduction from the Regional Budget allocation 1. Yes 3. No

INTERVIEWER REMARKS: IF NO.3a OR 3b=YA. IF 3a AND 3b = NO, THEN GO TO SECTION G2 4. What action was taken to overcome the delay or deduction in 2005?

A. PROPOSE ADDITIONAL BUDGET B. NO ACTION WAS DONE, JUST SIMPLY USE THE EXIST FUNDS V. OTHERS, _____________________________________________________________________

G2. Puskesmas Retribution and Return of Shared Revenue

1. Does the Health Dinas sets the target for Puskesmas services retribution? 1. Yes 3. No NO. 4

2. What are the considerations as the basis for the determination of such retribution target? A. BASED ON CERTAIN FORMULA (SUCH AS THE NUMBER OF HEADS OF FAMILIES IN THE COVERAGE AREA, ETC.)

B. BASED ON THE RETRIBUTION CAPACITY OF THE PUSKESMAS IN THE PREVIOUS YEAR V. OTHERS, _____________________________________________________________________

3. Did the Health Dinas discuss the retribution target with heads of Puskesmas in Fiscal Year 2005?

1. Yes 3. No

4. How much was the average of Puskesmas retribution target in Fiscal Year 2005? Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

5. What is the legal basis that regulates the revenue sharing between Puskesmas and Health Dinas?

1. LOCAL REGULATION No._________________________________________________________ 2. Head of Health Dinas Decree No. _________________________________________________ 5. Others, ____________________________________________________________________ 6. NONE

6. What is the percentage received by Puskesmas? └─┴─┴─┘percent 6. NOT APPLICABLE

7. Does the return of shared revenue from the Health Dinas to Puskesmas is only in form of cash? 1. Yes NO.9 3. No

8. What are other types of shared revenue return? A. MEDICINE D. MEDICAL SUPPLIES B. VACCINE E. MEDICAL EQUIPMENT C. CONTRACEPTION V. OTHERS, __________________________

9. Does Puskesmas has a flexibility to decide the allocation of the shared revenue? 1. Yes 3. No G3. Private Health Practice License

1. Is there any PERDA (Local Regulation) that regulates the tariff of practice licenses for private doctor/nurse/midwife?

1. Yes, Local Regulation (PERDA) No._________________________________________________ 3. No

2. Who is in charge to issues the practice license for private doctor/nurse/midwife? 1. District/City Government 5. District, ____________________________ 2. Health Dinas

Health Dinas

3. Is there any cost for issuing the license […]?

a. General doctor 1. Yes, Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. No

b. Midwife 1. Yes, Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. No

c. Nurses 1. Yes, Rp. └─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. No H. PUSKESMAS TARIFF

1. Is there any PERDA (Local Regulation) that regulates Puskesmas tariff? 1. Yes, (Local Regulation) PERDA No._________________________________________________ 3. No

2. Does Health Dinas discuss the decision on Puskesmas tariff with heads of Puskesmas? 1. Yes 3. No

3. How often does tariff get re-evaluated? 1. Annually 5. Others, ____________________________ 2. Between 1-2 years

4. Does the Head of Puskesmas have the authority to adjust the Puskesmas tariff (for example to solve the Puskesmas financial problem)?

1. Yes 3. No SECTION I

5. Does the Head of Puskesmas report the tariff adjustment to Health Dinas? 1. Yes 3. No I. MINIMUM SERVICE STANDARD (SPM)

1. According to you, does the government of this district/city would be able to meet the SPM set by the central government?

1. Yes 3. No

2. Why? 3. Is there any regulation in this district/city on SPM? 1. Yes, (Local Regulation) PERDA No. _________________________________________________

3. No SECTION J

4. In overall, does all Puskesmas have sufficient [.....] in term of SPM implementation?

a. Budget 1. Yes 3. No

b. Human Resources 1. Yes 3. No

c. Infrastructure/equipment 1. Yes 3. No

5. Is there any sanction from Health Dinas to Puskesmas that fail to meet the SPM? 1. Yes 3. No SECTION J

6. Please specify the sanctions

Health Dinas

J. DOCTOR RECRUITMENT

1. Who finalize the decision in the recruitment of […] that will be assigned at the Puskesmas?

1. Central Government/Department of Health 2. District/City Health Dinas 3. Head of Puskesmas 5. Others, ___________________________________________

INTERVIEWER REMARKS: IF THE HEAD OF PUSKESMAS IS NOT THE FINAL DECISION MAKER. 2. Does the head of Puskesmas involved in the final decision

making in the recruitment of [...]?

a. Medical Doctor 1 2 3 5 _______________________________________ 1. Yes 3. No

b. PTT Doctor (temporary staff) 1 2 3 5 _______________________________________ 1. Yes 3. No

c. Local Honorary Doctor 1 2 3 5 _______________________________________ 1. Yes 3. No K. MEDICINE, VACCINE, MEDICAL SUPPLIES AND MEDICAL EQUIPMENT PROCUREMENT

1. During 2005, did Health Dinas always able to meet the request of […] from Puskesmas?

2. In 2005, what was the average percentage of [...] request from Puskesmas that could be met by the Health Dinas?

3. What did Health Dinas do if the Puskesmas requests for […] was unable to met?

A. MEET THE NEXTREQUEST B. AUTHORIZE PUSKESMAS TO

PURCHASE FROM THIRD PARTIES C. DID NOT DO ANYTHING V. OTHERS,

___________________________

a. Medicine 1. Yes 3. No └─┴─┴─┘ percent A B C V, _____________________________

b. Vaccine 1. Yes 3. No └─┴─┴─┘ percent A B C V, _____________________________

c. Medical Supplies 1. Yes 3. No └─┴─┴─┘ percent A B C V, _____________________________

d. Medical Equipment 1. Yes 3. No └─┴─┴─┘ percent A B C V, _____________________________ L. RELATIONSHIP WITH HEALTH BOARD, PUSKESMAS, PRIVATE HEALTHCARE PRACTICES AND THE COMMUNITY L1. Health Board

1. Is there any health board in this district/city? 1. Yes 3. No SECTION L2

2. Does the existence of the board contribute to the health service improvement in this district/city? 1. Yes 3. No L2. Puskesmas

1. Did the health board conduct performance evaluation for all of the Puskesmas in 2005? 1. Yes 3. No SECTION L3

Health Dinas

2. In general, based on the evaluation results how many Puskesmas, out of all Puskesmas operated in this district/city, were considered to have good performance? └─┴─┘

L3. Private Healthcare Practices

1. Did the health board update the list of private practices in 2005? 1. Yes 3. No

2. Has the health board ever annul any private practice license during 2005? 1. Yes 3. No

L4. Community/Public

1. Has the Dinas ever received criticism, complaints and suggestions from the community (e.g. the public hospital patients, Puskesmas and private practices) related with health services in 2005?

1. Yes 3. No SECTION M

2. What was the problem that usually highlighted? A. CONDITION OF HEALTH FACILITIES (SPACE AVAILABILITY,CLEANLINESS,ETC.) B. MEDICINE, VACCINE, CONTRACEPTION AND/OR MEDICAL SUPPLIES AVAILABILITY C. HEALTHCARE STAFF MANNER D. HEALTHCARE SERVICE TARIFF E. HEALTHCARE SERVICE HOURS F. MISDIAGNOSIS V. OTHERS, _____________________________________________________________________

3. What was your response to the delivered complaint, criticism and suggestion? A. ACCOMODATED THE COMPLAINTS/CRITICISM/SUGGESTION B. RESOLVED THE PROBLEM IMMEDIATELY, IF POSSIBLE C. DISCUSSED WITH RELEVANT STAFF/UNIT D. REPORTED TO DISTRICT HEAD/MAYOR E. DID NOT DO ANYTHING V. OTHERS, _____________________________________________________________________

M. TRANSPARENCY AND PARTICIPATION

1. Does Health Dinas actively publish/socialize program, budget and procedures of health service to the community?

1. Yes 3. No, because ___________________________________________________________________

2. Can the community learn about, and/or access the public documents (work plan, budget, and policy) in Health Dinas?

1. Yes, by using ________________________________________________________________ 3. No, because ___________________________________________________________________

3. In 2006, does Health Dinas have any agenda to improve the health service transparency and participation in this district/city?

1. Yes, namely __________________________________________________________________ 3. No, because ___________________________________________________________________

Health Dinas

DS. SECONDARY DATA

1. How many [...] works within this district/city Health Dinas service area?

A. Doctor └─┴─┴─┘ persons B. Midwife └─┴─┴─┘ persons

C. Nurse └─┴─┴─┘ persons

D. Non medical staff └─┴─┴─┘ persons

2. How many [...] work in Health Dinas office in this district/city?

A. Civil Servants └─┴─┴─┘ persons B. Non-Civil Servants └─┴─┴─┘ persons

FK. HARDCOPY DOCUMENT 1-4 ARE ONLY FOR PUSKESMAS THAT ARE RESPONDENTS OF GDS-2, AND SHOULD BE COPIED IF UNABLE TO BRING THE DOCUMENTS FROM THE PUSKESMAS.

1. LB-2 (LPLPO) JULY-DECEMBER 2005

2. LB-3 (KIA, NUTRITION, IMMUNIZATION AND P2M) PAST ONE MONTH

3. LB-4 (PUSKESMAS ACTIVITIES) PAST ONE MONTH

4. LT-1 (PUSKESMAS BASIC DATA) AND LT-2 (EMPLOYMENT DATA) OF 2005 2005

5. LIST OF EMPLOYEE’ SALARIES OF ALL THE PUSKESMAS IN THIS DISTRICT/CITY JULY-DECEMBER 2005 TLP. RESPONDENT’S AVAILABLE PHONE NUMBER



1. WHAT IS THE MOST FREQUENTLY USED LANGUAGE DURING THE INTERVIEW? 1. JAVA 7. MADURA 13. NIAS 19. LAMPUNG 2. SUNDA 8. SASAK 14. PALEMBANG 20. DAYAK 3. BALI 9. MINANG 15. SUMBAWA 21. INDONESIA 4. BATAK 10. BANJAR 16. TORAJA 95. OTHERS,________________ 5. BUGIS 11. BIMA 17. LAHAT

Health Dinas

6. CHINESE 12. MAKASAR 18. BETAWI






CONFIDENTIAL


PRIVATE HEALTH PROVIDER

Private Health Provider ID └─┴─┘└─┴─┘ 36 └─┴─┘

A. LOCATION OF PRIVATE HEALTH PRACTICES

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Subdistrict Code └─┴─┴─┘ 4. Village/Kelurahan *) Code └─┴─┴─┘ 5. Address 6. Postal Code └─┴─┴─┴─┴─┘ 7. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ *) Select One B. RESPONDENT IDENTITY

1. What is you complete name? 2. What is your occupation? 1. Doctor 3. Nurse/Paramedic

2. Midwife 3. What is your employment status? 1. Civil Servant 3. Non-Civil Servant NO. 5 4. What is your employment rank? └─┴─┴─┘/└─┘ 5. Gender 1. Male 3. Female 6. What is your age at the moment? └─┴─┘ years 7. What is the highest level of education you completed? 1. Senior High School/SMK/islamic High School (MA)

2. Diploma I/II 3. Diploma III/Bachelor 4. Diploma IV/Bachelor/Doctor 5. Post Graduate (S2/Specialist/S3/Super specialist)

Private Health Provider

95. Others, _______________________________________________________________________

8. Since when have you opened your private practice _____ (SEE ANSWER NO.2)? Year └─┴─┴─┴─┘ 9. How long have you been practicing in this location? (CONVERT INTO MONTHS) INTERVIEWER REMARKS: IF THE RESPONDENT HAS MORE THAN ONE PRACTICE

LOCATIONS, PLEASE REFER TO THE ONE THAT RESPONDENT CONSIDER TO BE THE MAIN PRACTICE.

└─┴─┴─┘ months

10. Other than this location, do you have other private practice? 1. Yes 3. No NO. 12

11. In how many locations do you open private practice, other than in this location? └─┴─┘locations 12. Other than opening private practice, do you have other occupations in the health sector? 1. Yes 3. No NO. 16

13. Where is the location of that occupation? 1. Community Health Center (Puskemas) 6. Military Unit or Community Sub health Centre (Pustu)

2. Public Hospital (RSUD) 7. Private Health Facilities 3. Health Dinas Employees 8. Private Non-medical Facilities 4. State-owned Health Facilities 95. Others, ____________________________

(BUMN)/Regional Enterprises (BUMD) 5. Other Department-owned Health Facilities

14. How far is your other occupation’s location from this practice location? (IN METERS) └─┴─┘. └─┴─┴─┘ meters 15. What transportation you normally use to get to the location of your other occupation from this

practice location? A. On Foot D. Car B. Bicycle E. Boat C. Motor cycle V. Others, ____________________________

16. What was the percentage of all of your private practices income from the total income of all your occupations last month?


Now, we would like to ask about the condition of your practice

17. What is the ownership of the building in which your practice located? 1. Private residence 5. Non-residence private property 2. Company/government house 6. Non-health Government Facility 3. Government health facility 95. Others, ___________________________ 4. Other rented place

18. What is the lighting source for this practice? 1. PLN (State Electricity Company) Electricity 3. Private generator 2. Non PLN Electricity 5. Others, ____________________________

19. What is the potable water source that most frequently used by this practice? 1. Water utilities(PAM)/piped water into dwelling/yard/plot 2. Public tap/standpipe 3. Drilled well


4. Protected dug well 5. Protected spring 6. Rainwater collection 7. Bottled water 8. Unprotected dug well 9. Unprotected spring 10. Water vendor truck 11. Surface water (river, stream, dam, lake/fishpond, channel, water channel)

C. HEALTH SERVICES C1. Main Problem in Health Services

1. Please specify 3 main problems in providing health service in this practice 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

C2. Service hours

1. Does this practice have regular/routine service hours? 1. Yes Fill NO.2-5 3. No NO. 6

Days 2. Open hour, morning 3. Closing time, morning 4. Open hour, afternoon 5. Closing time, afternoon

a. Monday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ b. Tuesday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ c. Wednesday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ d. Thursday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ e. Friday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ f. Saturday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ g. Sunday └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ └─┴─┘:└─┴─┘ NO. 7

6. In average, how many weekly working hour you work in this practice? └─┴─┴─┘ hours 7. Do you willing to provide health services whenever needed? 1. Yes 3. No

8. Do you willing to visit the patients whenever needed? 1. Yes 3. No


C3. Availability of Health Services and Service Tariff in Primary Practice Location

1. Other than service price, do you also charged administration fees for patients? 1. Yes, Rp. └─┴─┴─┘.└─┴─┴─┘ 3. No

2. Does this practice location provide service for […]? 3. How much is the service price for […]?

a. In patient 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per day

b. Out patient 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per visit

c. Medical consultation + Medicine 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per visit

d. Injection 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per injection

e. Circumcision 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

f. Tuberculosis treatment 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per visit

g. Pre natal Care 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per visit

h. Delivery/Laboring 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

i. Primary immunization for children (BCG, DPT, Polio, Measles, Hepatitis B)

1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘

Per antigen/dose

j. Other immunization for children (MMR, meningitis, etc.)

1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘

Per antigen/dose

k. Birth Control Pills 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per dose

l. IUD Lippes-loop/spiral installment 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

m. IUD Lippes-loop/spiral removal 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

n. IUD Copper T Installment 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

o. IUD Copper T removal 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

p. Injectable Birth Control 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

q. Implant insertion 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment

r. Implant removal 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘ Per treatment


D. MEDICINE AVAILABILITY

1. Does this practice have medicine supplies for patients? 1. Yes 3. No SECTION E

2. How do you get the medicine? A. BUY THEM AT THE PHARMACY B. BUY FROM MEDICAL SUPPLIERS C. USE/BORROW FROM PUSKESMAS/HOSPITAL SUPPLIES D. DONATION/AID FROM THE GOVERNMENT E. DONATION/AID FROM MEDICAL SUPPLIERS V. OTHERS, _____________________________________________________________________

3. How many percent of such medicine supplies did you purchase by yourselvesf? └─┴─┴─┘ percent

Dose prescribed for adult patients Medicine 4. Does this practice provide […]? 5. Amount 6. Package

1. Tablet 4. Bottle 2. Capsul 5. Sachet 3. Caplet 6. Injection

7. For how many days?

8. Medicine price […], other than examination price?

9. At this moment, do you have […] in this practice?

a. Antibiothics

1. Amoxicillin (500mg) 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

2. Chloramphenicol 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

3. Thiamphenicol 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

4. Co-trimoxazole 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

5. Cephalosporin 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

b. Analgetic

1. Antalgin 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

c. Antipiretic

1. Paracetamol 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

d. Anti Tuberculosis

1. INH 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

2. Ethambutol 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

3. Rifampicin 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

e. Anti allergies, _____________________

1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

f. Flu & Cold 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No


Dose prescribed for adult patients Medicine 4. Does this practice provide […]? 5. Amount 6. Package

1. Tablet 4. Bottle 2. Capsul 5. Sachet 3. Caplet 6. Injection

7. For how many days?

8. Medicine price […], other than examination price?

9. At this moment, do you have […] in this practice?

Medicine,________________

g. Anti Hypertension,__________________

1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

h. Anti diabetic oral, __________________

1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

i. Oral Rehydration Salt (ORS) 1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

j. Iron Tablets,_______________________

1. Yes 3. No └─┴─┴─┘ 1 2 3 4 5 6 └─┴─┘ Rp. └─┴─┴─┘.└─┴─┴─┘ 1. Yes 3. No

E. AVAILABILITY OF MEDICAL SUPPLIES AND MEDICAL EQUIPMENT

1. Does this practice have [...] (in good condition) available at the moment?

a. Stethoscope 1. Yes 3. No

b. Sphygmomanometer 1. Yes 3. No

c. Thermometer 1. Yes 3. No

d. Sterilizers (such as autoclave, heater, dan boiler vessel) 1. Yes 3. No

e. I.V. set and stand-part 1. Yes 3. No

f. Disposable syringe 1. Yes 3. No

g. Sewing needle and thread 1. Yes 3. No

f. Disinfectant (such as alcohol swab, etc.) 1. Yes 3. No

g. Bandage 1. Yes 3. No

h. Hand wash basin/cleansing basin 1. Yes 3. No

2. What is the percentage of the medical supplies/equipment that you buy yourselves? └─┴─┴─┘ percent


F. PATIENTS F1. Number of patients

1. In average, how many patients visit this practice per day? └─┴─┴─┘ persons 2. How many patients visited this practice yesterday? INTERVIEWER REMARKS: YESTERDAY REFERS TO THE LAST DAY THE PRACTICE

WAS OPENED.

└─┴─┴─┘ persons

F2. Patients from Poor Families (GAKIN)

1. Do you provide payment reduction or free services for the poor patients? 1. Yes, everyone 2. Yes, not everyone 3. No

2. Do you provide payment reduction or free services for the patients with health cards, JPS-BK, poor cards, Askeskin?

1. Yes, everyone 2. Yes, not everyone 3. No

F3. Patients Data Record

1. Do you keep the medical record/data of your patients? 1. Yes 3. No SECTION F4

2. Who keeps the record? 1. Doctor/midwife/paramedic/nurse 2. Patients 3. Doctor/midwife/paramedic/nurse AND the patient

3. What kind of data/information noted in the record? A. Patient data E. Medical prescription B. Visiting Time F. Reference to other facilities C. Diagnosis V. Others, __________________________ D. Action/treatment

F4. Reference

1. If the patient must be referred to other facilities, where would you refer the patient to? A. Public Hospital D. General Doctor B. Private Hospital E. Specialist C. Puskesmas V. Others, ____________________________

2. Why do you refer to that facility? A. THE NEARNESS OF THE LOCATION D. FAMILIARITY WITH STAFF IN THAT FACILITY

B. AFFORDABILITY OF THE COST V. OTHERS, __________________________ C. BEST SERVICE


F5. Criticism, Complaint and Suggestion

1. Have you ever received criticism, complaint and suggestion from your patient regarding the health services you provide in the last one year?

1. Yes 3. No SECTION H

2. What issues were frequently addressed? A. CONDITION OF HEALTH FACILITIES (AVAILABILITY OF ROOM, SANITATION, ETC) B. AVAILABILITY OF MEDICINE, VACCINE, CONTRACEPTION AND/OR MEDICAL SUPPLIES C. MEDICAL STAFF MANNER D. HEALTH SERVICE PRICE E. HEALTH SERVICE HOURS F. MISDIAGNOSE V. OTHERS, _____________________________________________________________________

3. How do you respond to the complaint, criticism and suggestion from your patients? A. PUT THE COMPLAINT, CRITICISM AND SUGGESTION INTO RECORDS B. FOLLOW UP DIRECTLY C. IGNORE V. OTHERS, _____________________________________________________________________

H. RELATIONSHIP WITH PUSKESMAS AND HEALTH DINAS

1. Have you ever received supervisory and monitoring visit from […] in this location? 2. How many times did the visit happen in the last one year?

a. Puskesmas 1. Yes 3. No └─┴─┘ times b. District/City Health Dinas 1. Yes 3. No └─┴─┘ times

3. In the last one year, did you make any formal or informal report regarding [...] to the Puskesmas?

a. Medical treatment 1. Yes 3. No

b. Medical treatment under surveillance 1. Yes 3. No

c. Birth Control Services 1. Yes 3. No

d. KIA/Mother and Child Care 1. Yes 3. No


I. PRACTICE LICENSE

1. Do you have a license to open a private practice in this location? 1. Yes 3. No SECTION J

2. When was the license issued? Year └─┴─┴─┴─┘ 3. Who issued the license? 1. Provincial Health Dinas 4. Independent board/institution

2. District/City Health Dinas 5. Others, ____________________________ 3. Professional association

4. Do you have to extended the license? (upon the expire date of the license validity) 1. Yes 3. No SECTION J 8.UNKNOWN SECTION J

5. What is the requirement to extend the license? A. Performance evaluation C. Site visit to the practice location B. Reccomendation letter V. Others, ____________________________

J. CAPACITY BUILDING

1. When was the last time you […]? 1. < 6 months ago 2. 6 months – 1 year ago 3. > 1 year ago

2. What is the literature source or the organizer of the training/seminar/course? A. Health Department D. Professional association B. Provincial Health Dinas E. Private (medical company etc) C. District/City Health Dinas V. Others, __________________________

a. Read the Standard Operational Procedures (SOP)

1 2 3 A B C D E V _____________________________________________________________

b. Patricipate in clinical training 1 2 3 A B C D E V _____________________________________________________________

c. Attend a seminar 1 2 3 A B C D E V _____________________________________________________________

d. Take a short course 1 2 3 A B C D E V _____________________________________________________________ OL. DIRECT OBSERVATION INTERVIEWER REMARKS: DO NOT ASK THIS SECTION TO THE RESPONDENT! OL1. GENERAL INFORMATION

1. DOES THIS PRACTICE HAVE [...]?

a. WAITING ROOM 1. YES 3. NO

b. EXAMINATION ROOM 1. YES 3. NO

c. IN PATIENT ROOM 1. YES 3. NO

d. MEDICINE ROOM 1. YES 3. NO


e. BATHROOM/TOILET WITH RUNNING WATER 1. YES 3. NO

OL2. EXAMINATION ROOM

1. HOW IS THE FLOOR CLEANLINESS OF THE EXAMINATION ROOM? 1. CLEAN 3. DIRTY

2. HOW IS THE WALL CLEANLINESS OF THE EXAMINATION ROOM? 1. CLEAN 3. DIRTY

3. IS THERE ANY PARTITION CURTAIN IN THE EXAMINATION ROOM? 1. YES 3. NO

4. HOW IS THE CURTAIN CLEANLINESS IN THE EXAMINATION ROOM? 1. CLEAN 3. DIRTY

5. WHAT KIND OF FACILITY YOU USE FOR HAND WASHING? 1. SINK WITH CLEAN WATER 3. NO FACILITIES 2. CLEAN WATER CONTAINER

6. IS THERE AN EXAMINATION TABLE IN THE ROOM? 1. YES 3. NO

7. (SPECIFICALLY FOR PRIVATE MIDWIFE PRACTICE) IS THERE A OBSTETRICIAN TABLE IN THE EXAMINATION ROOM?

1. YES 3. NO

OL3. ROAD CONDITION AND TRANSPORTATION

1. DESCRIBE THE ROAD THAT LEADS TO THIS PRACTICE LOCATION!

2. WHAT TRANSPORTATION DOES PEOPLE USED TO GET TO YOUR PRACTICE? A. ON FOOT D. CAR

B. BICYCLE E. BOAT C. MOTORCYCLE V. OTHERS,___________________________




CONFIDENTIAL


H E A D O F PUBLIC H O S P I T A L

Hospital Head ID └─┴─┘└─┴─┘ 37 01 A. HOSPITAL LOCATION

1. Province Code └─┴─┘ 2. District/City *) Code └─┴─┘ 3. Hospital’s Name 4. Address 5. Postal Code └─┴─┴─┴─┴─┘ 6. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 7. Facsimile └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 8. Internet website and/or Email Address (if available) *) Select One B. RESPONDENT IDENTITY

1. What is your complete name? 2. What is your position in this Hospital? 1. Director 5. Others, ____________________________

2. DeputyDirector

3. What is your employment status? 1. Civil Servant (PNS) 3. Non-Civil Servant NO.5


6. What is your age at the moment? └─┴─┘ years 7. What is the highest level of education you have completed? 1. Senior High School/Vocational/Islamic High School (MA)

2. Diploma I/II 3. Diploma III/Under Graduate

Head of Public Hospital

4. Diploma IV/S1/Doctor 5. Post Graduate (S2/Specialist/S3/Super Specialist) 95. Others, _______________________________________________________________________

8. Since when have you become _____ (SEE ANSWER NO.2) in this Hospital? Month └─┴─┘ year └─┴─┴─┴─┘ C. GENERAL INFORMATION C1.Hospital Legal Entity

1. What is the legal entity of this hospital? 1. Public Utility (BLU) 2. Private Company (PT) SECTION C2 3. State-owned Company (Perjan) SECTION C2 4. PNBP (Non Tax State Enterprise) SECTION C2 5. Others, _________________________________________________________ SECTION C2

2. When was this hospital established as Public Utility? Month └─┴─┘ year └─┴─┘ C2. Number of Bed

1. How many beds for [...] this hospital has?

a. V VIP Class └─┴─┴─┘units

b. VIP Class └─┴─┴─┘units

c. I Class └─┴─┴─┘units

d. II Class └─┴─┴─┘units

e. III Class (total III Class) └─┴─┴─┘units C3. Bed Occupancy Rate

1. What was the percentage of the bed occupancy rate of [...] in 2003?



a. II Class └─┴─┴─┘ percent └─┴─┴─┘ percent └─┴─┴─┘ percent b. III Class (total III Class) └─┴─┴─┘ percent └─┴─┴─┘ percent └─┴─┴─┘ percent c. Total average in all classes └─┴─┴─┘ percent └─┴─┴─┘ percent └─┴─┴─┘ percent


C4. Occupancy Rate of Poor Families in III Class

1. What was the percentage of III class occupancy by patients with health insurance for the poor program (patients with health cards, Askeskin, Statement of Poor, etc) in [...]? (estimated)

a. 2003 └─┴─┴─┘ percent b. 2004 └─┴─┴─┘ percent c. 2005 └─┴─┴─┘ percent

D. AGREEMENT OF THIS HOSPITAL WITH PT ASKES REGARDING PKPS BBM –BK (COMPENSATION PROGRAM TO REDUCE FUEL SUBSIDY ON HEALTH SECTOR )

INTERVIEWER REMARKS: BASED ON PKPS BBM-BK MANUAL, FROM THE DEPARTMENT OF HEALTH, THE AGREEMENT BETWEEN HOSPITAL AND PT ASKES IS DRAWN UP AS MEMORANDUM OF UNDERSTANDING OR COOPERATION AGREEMENT (PKS). 1. Is there any agreement between this hospital and PT ASKES on the healthcare program for poor

community?

1. Yes 3. No SECTION E

2. When was the agreement signed? Month └─┴─┘ year └─┴─┘

3. What was/were the negotiated issue/s? a. Type of service 1. Yes 3. No

b. Tariff/Price 1. Yes 3. No

c. Number of patients that can be served 1. Yes 3. No

d. Verification procedures for patient’s identity 1. Yes 3. No

e. Verification procedures for Service 1. Yes 3. No

f. Claim and payment (billing) process 1. Yes 3. No

g. Complaint and settlement process 1. Yes 3. No

Services 4. Does [...] included as the type of service agreed with PT ASKES? 5. How much is the price for [...] base on the agreement with PT ASKES?

a. Advanced Out patient (RJTL): 1. Medical consultation 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 2. Dental examination and treatment 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 3. Birth control services 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 4. High risk pregnancy examination 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

b. Advanced In patient (RITL): 1. In patient accommodation in III Class 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 2. Medical consultation 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘


3. Diagnostic Support Facility a. Laboratory service 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ b. Radiograph 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ c. Electromedic 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

4. Surgery: a. Medium 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ b. Large 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ c. Specialist 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

5. Intensive Care (ICU, ICCU) 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 6. Births without complications 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ 7. Births with complications 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

c. Emergency Room Services 1. Yes 3. No Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

6. To which policy does agreed tariff refers to? A. Local Regulations on ___________________________________________________ B. Ministry of Health’s Decree No. 56/2005 V. Others, ______________________________________________________________________

7. How many poor patient can be served by this hospital based on the agreement? 1. └─┴─┴─┘.└─┴─┴─┘persons 6. NOT APPLICABLE (NO LIMIT) SECTION E

8. What data based the number? A. Data from the Central Statistics Bureau (BPS) B. Data from Department of Health C. Data from PT. ASKES V. Others, _______________________________________________________________________

E. REQUIREMENTS TO GET HEALTH INSURANCE FOR THE POOR (ASKESKIN)

1. To get Askeskin service, what are the documents required from the patients with reference? (PATIENTS WITH REFERRENCE FROM COMMUNITY HEALTH CENTER (PUSKESMAS))

2. Please describe your policy for a poor patient who comes to this hospital without reference?

3. Please describe your policy for a poor patient who wants to get Askeskin services but does not have any document when coming to this hospital?

4. Please describe your policy for patient without Askeskin but during the treatment claim that he/she is poor and unable to pay the service?


5. Is there any officer from PT ASKES who monitor and verify the proposals for Askeskin services in this Hospital?

1. Yes 3. No

F. SUBMITTING ASKESKIN CLAIMS FROM HOSPITAL TO PT ASKES

1. When does this hospital submit Askeskin claims to PT ASKES? 1. Monthly 2. Quarterly 5. Others, _______________________________________________________________________

2. How long does PT ASKES usually take to disburse the payment from the moment the claims submitted? └─┴─┴─┘ days

3. Has the hospital ever experienced arrears in payment (partially or totally) for over 2 weeks since the claims submitted to PT ASKES?

1. Yes 3. No NO. 5

4. How long is the average period of that arrears? (CONVERT INTO DAYS) └─┴─┴─┘ days

5. How much was the total average claim for Askeskin that being paid PT ASKES in 2005? └─┴─┴─┘ percent

6. Has there been any claims from this hospital that being rejected by PT ASKES? 1. Yes 3. No SECTION G

7. What was the reason? A. PATIENTS WERE CONSIDERED NOT ELIGIBLE/DID NOT MEET THE REQUIREMENTS. B. INCOMPLETE CLAIM DOCUMENTS/NOT IN COMPLIANCE. C. TYPES OF HEALTH SERVICES WERE NOT IN ACCORDANCE WITH THE AGREEMENT. D. EXPENSES EXCEED STIPULATIONS AND/OR AGREEMENT. V. OTHERS, _____________________________________________________________________

G. IMPACT OF ASKESKIN PROGRAM ON HOSPITAL

G1. Hospital Budget

1. What is the total revenue of this hospital in [...]? a. 2004 Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘ b. 2005 Rp. └─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘.└─┴─┴─┘

2. In 2005, what was the percentage of revenue from the Askeskin program compared to the total revenue of the hospital? └─┴─┴─┘ percent

3. From total income from Askeskin, how many percent is allocated/used for [...]?

a. Administration └─┴─┴─┘ percent b. Beds and equipment └─┴─┴─┘ percent c. Medicine └─┴─┴─┘ percent


d. Medical supplies └─┴─┴─┘ percent e. Food └─┴─┴─┘ percent f. Medical doctor services └─┴─┴─┘ percent g. Others, _____________________________________________ └─┴─┴─┘ percent h. Others, _____________________________________________ └─┴─┴─┘ percent i. Others, _____________________________________________ └─┴─┴─┘ percent

G2. Hospital Planning and Management

1. What are the impacts of the Askeskin program on this hospital? A. IMPROVEMENT OF HOSPITAL INCOME B. IMPROVEMENT OF STAFF INCOME C. INCREASE IN OPERATIONAL EXPENSES OF HOSPITAL D. INCREASE IN WORK LOAD E. INCREASE IN NUMBER OF BEDS V. OTHERS, _____________________________________________________________________

H. ASKESKIN IMPLEMENTATION REPORT

1. To whom does the Askeskin implementation report of this hospital submitted to? A. PT. ASKES B. DISTRICT/CITY HEALTH DINAS V. OTHERS, _____________________________________________________________________

2. When does the report submitted? A. MONTHLY B. QUARTERLY C. ANNUALLY V. OTHERS, _____________________________________________________________________

I. CONSTRAINTS IN ASKESKIN IMPLEMENTATION

1. What are the primary constraints faced by this hospital in implementing Askeskin? (3 PRIMARY CONSTRAINTS)

1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

J. MEDIA TO DELIVER ASPIRATIONS

1. Has the Hospital ever received criticism, complaints and suggestions from patients/community regardingn the implementation of Askeskin program in the last 1 year?

1. Yes 3. No SECTION K 8.DO NOT KNOW SECTION K


2. What mechanism/device were used by the patients/community to delivered it? A. DIRECTLY DELIVERED TO THE HOSPITAL B. SUGGESTION BOX IN THE HOSPITAL OR GOVERNMENT OFFICE C. FORUM WITH VILLAGE/KELURAHAN OFFICIALS D. FORUM WITH SUB DISTRICT OFFICIALS E. FORUM WITH DISTRICT/CITY GOVERNMENT OFFICIALS F. FORUM WITH PROVINCIAL GOVERNMENT OFFICIALS G. MASS MEDIA (RADIO, TV, NEWSPAPERS, ETC.) H. FORUM WITH NON GOVERNMENT ORGANIZATION (LSM) I. FORUM WITH PUBLIC/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS, _____________________________________________________________________

3. What has been the most frequently delivered criticism, complaints and/or suggestions? A. CONDITION OF HEALTH FACILITIES (SPACE AVAILABILITY,CLEANLINESS,ETC.) B. MEDICINE, VACCINE, CONTRACEPTION AND/OR MEDICAL SUPPLIES AVAILABILITY C. HOSPITAL STAFF MANNER D. INCORRECT DIAGNOSES E. REJECTING PATIENT F. DISCRIMINATIVE IN GIVING SERVICE V. OTHERS, _____________________________________________________________________

4. How did the hospital respond to criticism, complaints and suggestions from the patients/public? A. PUT COMPLAINTS, CRITICISM AND SUGGESTIONS INTO RECORDS B. FOLLOW UP C. DELIVER IT TO THE HEALTH DINAS D. IGNORE V. OTHERS, _____________________________________________________________________

DS. SECONDARY DATA

1. How many [...] work in this hospital?

a. Medical Doctors └─┴─┴─┘ persons b. Midwives └─┴─┴─┘ persons c. Nurses └─┴─┴─┘ persons d. Non Medical Staff └─┴─┴─┘ persons

2. How many [...] works in this this hospital?

a. Civil Servants └─┴─┴─┘ persons b. Non Civil Servants └─┴─┴─┘ persons

CONFIDENTIAL


B U R EAU C R A T

Bureaucrat ID └─┴─┘└─┴─┘ 41 01 A. LOCATION 1. Province Code └─┴─┘ 2. District/City*) Code └─┴─┘ 3. Official Name of District Head’s/Mayor’s Office 4. Address 5. Postal Code └─┴─┴─┴─┴─┘ 6. Telephone └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 7. Fax └─┴─┴─┴─┘-└─┴─┴─┴─┴─┴─┴─┴─┘ 8. Internet sites and/or Email address (if available) *) Select one B. RESPONDENT’S IDENTITY INTERVIEWER REMARKS: IF INFORMATION FOR NO.1 AND 2 HAVE BEEN COLLECTED BEFORE THE INTERVIEW, THEY DO NOT NEED TO BE ASKED TO THE RESPONDENT.

1. What is your complete name? 2. What is your position? 1. District Head/Mayor

2. Vice District Head/Vice Mayor 3. District Secretary 4. Assistant of District Secretary of ___________________________________________ (field area)

3. Since when did you act as _____ (SEE ANSWER NO. 2)? Month └─┴─┘ year └─┴─┴─┴─┘ 4. What was your job/position prior to the current position?

Bureaucrat

5. What is your employment status? 1. Civil Servant (Pegawai Negeri Sipil/PNS) 2. Non-Civil Servant (Non-PNS)

6. Gender 1. Male 3. Female

7. What is your current age? └─┴─┘ year 8. What is the highest level of education you have completed? 1. High School/Vocational/Islamic High School 4. Diploma IV/S1

2. Diploma I/II 5. Master/Doctor (S2/S3) 3. Diploma III/Bachelor 95. Other , ____________________________

INTERVIEWER REMARKS: - QUESTION NUMBERS 9-11 REFER TO DISTRICT HEAD/MAYOR. - PLEASE TRY TO OBTAIN INFORMATION FOR NO. 9 FROM THE SECONDARY DATA. - ANSWER CAN BE MORE THAN 1. 9. Affiliation to political party OR Which parties/alliance of parties nominated the district head/mayor during the election?

A. Partai Nasional Indonesia Marhaenisme N. Partai Karya Peduli Bangsa B. Partai Buruh Sosial Demokrat O. Partai Kebangkitan Bangsa C. Partai Bulan Bintang P. Partai Keadilan Sejahtera D. Partai Merdeka Q. Partai Bintang Reformasi E. Partai Persatuan Pembangunan R. Partai Demokrasi Indonesia Perjuangan F. Partai Persatuan Demokrasi Kebangsaan S. Partai Damai Sejahtera G. Partai Perhimpunan Indonesia Baru T. Partai Golongan Karya H. Partai Nasional Banteng Kemerdekaan U. Partai Patriot Pancasila I. Partai Demokrat V. Partai Sarikat Indonesia J. Partai Keadilan Dan Persatuan Indonesia W. Partai Persatuan Daerah K. Partai Penegak Demokrasi Indonesia X. Partai Pelopor L. Partai Persatuan Nahdlatul Ummah Indonesia Y. REFUSE TO ANSWER M. Partai Amanat Nasional Z. Others, ____________________________

10. Was the district head/mayor borne in this district? 1. Yes 3. No

11. How long has district head/mayor lived in this district? (CONVERT INTO MONTHS) └─┴─┴─┘ Months C. AUTHORITIES OF DISTRICT GOVERNMENT

1. With the enforcement of Law No.32/2004 on Local Government, has there been a ‘tug-of-war’ of authorities between the district government and the provincial government?

1. Yes 3. No SECTION D


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D. HEALTH SECTOR POLICY

1. What are the 3 main priorities of the health sector policy in this district for fiscal year 2006? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

2. Does the district have enough budgets to implement health program which is in line with the policy you mentioned above?

1. Yes 3. No

3. Are you satisfied, less satisfied or unsatisfied with the support from the provincial and/or central government to the health services in this district?

1. Satisfied 2. Less satisfied 3. Unsatisfied

4. Why do you feel ___ (SEE ANSWER NUMBER 3)?

E. EDUCATION POLICY

1. What are the 3 main priorities of the education policy in this district for fiscal year 2006? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

2. Does the district have enough budgets to implement education program which is in line with the policy you mentioned above?

1. Yes 3. No

3. Are you satisfied, less satisfied or unsatisfied with the support from the provincial and/or central government to the education services in this district?

1. Satisfied 2. Less satisfied 3. Unsatisfied

4. Why do you feel ___ (SEE ANSWER NUMBER 3)? F. POVERTY REDUCTION

1. In which sectors does the poor in this district work? (MAXIMUM 3 SECTORS WITH THE MOST OF POOR POPULATION)

A. FARM F. MINING AND QUARRYING B. PLANTATION/ESTATE G. CONSTRUCTION C. LIVESTOCK FARM H. TRADE D. FISHERY I. TRANSPORTATION E. FORESTRY V. OTHERS, __________________________

2. In which area does the poor in this district live? (MAXIMUM 3 AREAS WITH THE MOST OF POOR POPULATION)

A. URBAN D. COASTAL AREA B. RURAL V. OTHERS, __________________________ C. FOREST/FORREST SURROUNDINGS

3. Does the district government have a special program for the poor? INTERVIEWER REMARKS: THE PROGRAM DEVELOPED BY THE DISTRICT ITSELF.

1. Yes 3. No SECTION G

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4. What is the program’s name? 1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________ 4. ______________________________________________________________________________ 5. ______________________________________________________________________________

G. COMPENSATION PROGRAM TO REDUCE FUEL SUBSIDY (PKPS BBM)

Program 1. Does the PKPS BBM [...] implemented in this district?

2. In brief, what is your opinion to the implementation of PKPS BBM [...]?

3. In brief, what is your suggestion to improve the effectiveness of the program [...]?

a. Unconditional Cash Transfer (SLT) 1. Yes 3. No

b. Health 1. Yes 3. No

c. Education 1. Yes 3. No

d. Rural Infrastructure

1. Yes 3. No

H. BUDGET H1. Additional Expenditure

1. Did the district government undertake the budget adjustment (ABT=Additional Expenditure) in fiscal year 2005?

1. Yes 3. No SECTION H2

2. Which sector received the largest additional budget? 3. Was the Additional Expenditure reflected/allocated in the regional budget (APBD)/amendment to

APBD or the accountability report of APBD? 1. Yes 3. No

H2. Budget Formulation Process

1. Has the 2006 APBD been approved? 1. Yes 3. No NO.3

2. When was the Regional Budget approved? Month └─┴─┘ year └─┴─┴─┴─┘ NO.4 3. Why the 2006 APBD has not yet approved? 4. Does the current APBD formulation procedures hindrance the formulation, ratification and 1. Yes 3. No SECTION H3

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disbursement process of 2006 APBD?

5. Why? H3. General Allocation Fund (DAU)

1. What was the percentage of DAU contribution to the 2005 APBD? └─┴─┴─┘ percent 2. Please rank 3 sectors which received the largest amount of DAU in fiscal year 2005 1. ______________________________________________________________________________

2. ______________________________________________________________________________ 3. ______________________________________________________________________________

3. What is the percentage of DAU contribution to the 2006 APBD? └─┴─┴─┘ percent 4. Please rank 3 sectors which received the largest amounts of DAU in fiscal year 2006

1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

5. The allocation of DAU 2006 nationally increased by 64.1 percent from fiscal year 2005. How many percent the DAU increase for this district APBD for fiscal year 2006 from fiscal year 2005? ___ (percent). Regarding the increase, does this district government found difficulties in settle on the DAU allocation for fiscal year 2006?

1. Yes 3. No SECTION I

6. What are the difficulties? I. TRANSPARENCY AND PARTICIPATION I1. Legal Umbrella on the Implementation of Transparency and Participation

1. Does this district government have the legal umbrella/local policy on government transparency and public participation?

1. Yes 3. No SECTION I2

2. In which form does the legal umbrella/policy? 1. Local Regulation 2. District Head/Mayor’s decree 3. Decree of the Regional House of Representatives (DPRD) 4. Consensus between the Government of the District and the DPRD 5. Others, _______________________________________________________________________

3. What is the name of the legal umbrella/policy? I2. Active Dissemination of Public Documents

1. Does this district government actively publish documents [...] for public view?

a. Local Regulation 1. Yes 3. No

b. Accountability Report for the APBD implementation 1. Yes 3. No

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I3. People’s Access to Public Documents

1. Does this district government provide an opportunity to the people to learn about and understand the APBD?

1. Yes 2. Yes, by considering the purpose/objective of using the data 3. No

J. MEDIA TO DELIVER ASPIRATIONS

1. Does this district government have a specific organization unit (unit/body/institution) assigned to accommodate public aspirations/complaints/criticisms/suggestions?

1. Yes, specify___________________________________________________________________ 3. No

2. What mechanism or media that this district government mostly used to obtain/identify public aspirations?

A. DIRECT INFORMATION FROM THE PEOPLE TO THE OFFICERS IN THE FIELD B. INFORMATION VIA COMPLAINT BOX C. FORUM WITH OFFICIALS AT VILLAGE /KELURAHAN LEVEL D. FORUM WITH OFFICIALS AT SUBDISTRICT LEVEL E. FORUM WITH OFFICIALS AT DISTRICT LEVEL F. FORUM WITH OFFICIALS AT PROVINCE LEVEL G. MEDIA (RADIO, TV, NEWSPAPERS, DLL) H. FORUM WITH NON GOVERNMENT ORGANIZATIONS (NGO) I. FORUM WITH COMMUNITY/RELIGIOUS FIGURES J. BUSINESS FORUM V. OTHERS, _____________________________________________________________________

K. MISCELLANEOUS 1. Does this district have any system/institution that undertakes “early detection” of conflict

potential (such as a crisis center)? 1. Yes 3. No

2. Has there ever been any post-crisis management (such as internal displaced people management, infrastructure rehabilitation, provision of aid, relocation) conducted in this district?

1. Yes 3. No

3. Has the district head/mayor ever been protested by the people for issuing certain policy in 2005? 1. Yes, └─┴─┘ times 3. No SECTION TLP

4. From various rallies of protests, what was the issue/problem that considered to be the most urgent?

1. ______________________________________________________________________________ 2. ______________________________________________________________________________ 3. ______________________________________________________________________________

5. How did the district head/mayor response to the issue?

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1. WHAT IS THE MOST FREQUENTLY USED LANGUAGE DURING THE INTERVIEW?

1. JAVA 7. MADURA 13. NIAS 19. LAMPUNG 2. SUNDA 8. SASAK 14. PALEMBANG 20. DAYAK 3. BALI 9. MINANG 15. SUMBAWA 21. INDONESIA 4. BATAK 10. BANJAR 16. TORAJA 95. OTHERS,________________ 5. BUGIS 11. BIMA 17. LAHAT 6. CHINESE 12. MAKASAR 18. BETAWI




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