Primary Research Questionnaire

A primary research questionnaire can be used for several purposes. This is to be administered directly on the target group through face to face interview, focal interviews, etc. The following sample primary research questionnaire finds out the nutrition and health of a family.

Sample Primary Research Questionnaire:

Name:                       ______________________________

Contact number: ______________________________

Gender:             ______________________________

Age:                  ______________________________

Address:            ___________________________________________________

Q1. Please tick the right option regarding your family income level.

a)   < $ 10,000

b)   $ 10,000 – $ 30,000

c)   $ 30,000 – $ 60,000

d)   $ 60,000 – $ 100,000

e)   > $ 100,000

Q2. Please enter the following details of your family.

Name: ____________ Age: ________ Relation: _________ Occupation: ________________

Name: ____________ Age: ________ Relation: _________ Occupation: ________________

Name: ____________ Age: ________ Relation: _________ Occupation: ________________

Name: ____________ Age: ________ Relation: _________ Occupation: ________________

Q3. Do any of your family members currently have health illness?

a)   Yes

b)   No

Q4. If the answer to the above question is ‘yes’, please mention the following details.

Name: ______________ Illness: ______________________ Status: ____________________

Name: ______________ Illness: ______________________ Status: ____________________

Q5. Have you taken insurance for your family members?

a)   Yes

b)   No

c)   Not for all

If ‘not for all’, mention the names of the family members who have no insurance

Name1: _______________

Name2: _______________

Q6. Please tick the right option among the following

a)   We are a vegetarian family

b)   All family members are non-vegetarian

c)   Some of the family members are vegetarian and some are non-vegetarian

d)   Other _____________________________________________________

Q7. How much importance is given to the nutrition requirements of the family?

a)   Very little

b)   Little

c)   Moderate

d)   Very much

Q8. Please give your views on the health of your family

________________________________________________________________