[Note: This module should be filled in for every member of the household, starting from the eldest to the youngest member of the family.
Should the family have more than 9 members, the following page of the family household should be filled in.]

Household Information Panel: HH

HH1. PSU: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer number: _ _

HH4. Supervisor name and number:

HH5. Day/month/year of interview _ _ / _ _ / _ _ _ _

HH8. Name of head of household: ____

After all questionnaires for the household have been completed, fill in the following information

HH9. Result of HH interview:

HH10. Respondent to HH questionnaire

HH11. Total number of household members: _ _

HH12. No. of women eligible for interview: _ _

HH13. No. of women questionnaires completed: _ _

HH14. No. of children under age 5: _ _

HH15. No. of under-5 questionnaires completed: _ _

Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as call-back times, incomplete individual interview forms, number of attempts to re-visit, etc.

HH16. Data entry clerk: _ _

Household listing form: HL

All members of the family should be registered here. Their registration should start from the head of the household in line 01. List all household members (HL2) their relationship to the household head, (according to age). Should this page not be enough for all the members of the family (many members in one family), continue to the following page by signing in this square

HL1. Line no.: _ _

HL2. Name: ____

HL3. What is the relationship of (name) to the head of the household?

HL4. Is (name) male or female?

HL5. How old is (name)? How old was (name) in his/her last birthday?
Record in Completed years
If under 1 yrs old put "00"
HL6. Eligible for women's interview

HL7. Eligible for child labour module
For each child age 5-14: Who is the mother or primary caretaker of this child?

HL8. Eligible for under-5 interview
For each child under 5: Who is the mother or primary caretaker of this child

MODULE OF HOUSEHOLD LIST (MOD HL2)
To be administered to all members of the Household.

HL2ID. Line no.: _ _

HLMS. Which is your marital status today?
Circle one of the possibilities below:

HLR. What is your religion?

HLEG. To what ethnic group do you belong?

For children age 0-17 years ask HL9-HL12

HL9. Is (name's) natural mother alive?

HL10. If alive: Does (name's) natural mother live in this household?

HL11. Is (name's) natural father alive?

HL12. If alive: Does (name's) natural father live in this household?

Education Module: ED

This page should be filled in for the family members over 5 years of age.

For household members age 5 and above

ED1. Line no. _ _

ED2. Has (name) ever attended school or preschool?

ED3. What is the highest level of school (name) attended? What is the highest grade (name) completed at this level?

For household members age 5-24 years

ED4. During the (2005-2006) school year, did (name) attend school or preschool at any time?

ED5. Since last (day of the week), how many days did (name) attend school?

ED6. During this/that school year, which level and grade is/was (name) attending?

ED7. Did (name) attend school or preschool at any time during the previous school year, that is (2004-2005)?

ED8. During that previous school year, which level and grade did (name) attend?

Water and sanitation module: WS
These questions should be answered by one of the members of the family

WS1. What is the main source of drinking water for members of your household?

WS2. What is the main source of water used by your household for other purposes such as cooking and handwashing?

WS3. How long does it take to go there, get water, and come back?

WS4. Who usually goes to this source to fetch the water for your household?
Probe: Is this person under age 15? What sex?
Circle code that best describes this person.

WS5. Do you treat your water in any way to make it safer to drink?

WS6. What do you usually do to the water to make it safer to drink?
Anything else?
Record all items mentioned.
WS7. What kind of toilet facility do members of your household usually use?

WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

Household characteristics module: HC

These questions should be answered by the head of the household

HC2. How many rooms in this household are used for sleeping?

HC2A. How much is the surface of your household?

HC3. Main material of the dwelling floor:

HC4. Main material of the roof.

HC5. Main material of the walls.

HC6. What type of fuel does your household mainly use for cooking?

HC8. Is the cooking usually done in the house, in a separate building, or outdoors?

HC9. Does your household have:






HC10. Does any member of your household own:





Child labour module: CL

Mothers/caretakers should be asked for children 5 to14 years old. Please circle the line number of the respective child.

CL1. Line no. _ _

CL3. During the past week did (name) any kind of work for someone who is not a member of this household?
If yes: For pay in cash or kind?

CL4. If yes: Since last (day of the week), about how many hours did he/she do this work for someone who is not a member of this household?

CL5. During the past year, did (name) do any kind of work for someone who is not a member of this household?
If yes: For pay in cash or kind?

CL6. During the past week, did (name) help with housework such as cooking, shopping, cleaning, washing, water-supplying, baby-sitting?

CL7. If yes: Since last (day of the week), about how many hours did he/she spend doing these chores? _ _

CL8. During the past week, did (name) do any other family work (on the farm or in a business or selling goods in the street)

CL9. If yes: Since last (day of the week), about how many hours did he/she do this work? _ _

Child discipline module: CD

Table 1: Children aged 2-14 years eligible for child discipline questions
Review the household listing and list each of the children aged 2-14 years below in order according to their line number (HL1). Do not include other household members outside of the age range 2-14 years. Record the line number, name, sex, age, and the line number of the mother or caretaker for each child. Then record the total number of children aged 2-14 in the box provided (CD7).

CD1. Rank no.

CD2. Line no. from HL1.

CD3. Name from HL2.

CD4. Sex from HL4.

CD5. Age from HL5.

CD6. Line no. of mother/caretaker from HL7 or HL8.

CD7. Total children aged 2-14 years _ _

If there is only one child age 2-14 years in the household, then skip table 2 and go to CD11 to administer child discipline questions for that child.


Table 2: Selection of random child for child discipline questions
Use this table to select one child between the ages of 2 and 14 years, if there is more than one child in that age range in the household. Look for the last digit of the household number from the cover page. This is the number of the row you should go to in the table below. Check the total number of eligible children (2-14).
This is the number of the column you should go to.
Find the box where the row and the column meet and circle the number that appears in the box.


CD8. Last digit of the questionnaire number 0-9
Total number of eligible children in the household 1-8+
[Table omitted]

CD9. Record the rank number of the selected child from table 2 above

Identify eligible child aged 2 to 14 in the household using the tables on the preceding page, according to your instructions. Ask to interview the mother or primary caretaker of the selected child (identified by the line number in CD6).

CD11. Write the name and line number of the selected child

CD12. All adults use certain ways to teach children the right behaviour or to address a behaviour problem. I will read various methods that are used and I want you to tell me if you or anyone else in your household has used this method with (name) in the past month.

CD12A. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

CD12B. Explained why something (the behavior) was wrong.

CD12C. Shook him/her.

CD12D. Shoute, yelled at or screamed at him/ her, dumb, lazy or another name like that

CD12E. Gave him/her something else to do.

CD12F. Spanked, hit or slapped him/her on the bottom with bare hand.

CD12G. Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.

CD12H. Called him/her dumb, lazy, or another name like that.

CD12I. Hit or slapped him/her on the face, head or ears.

CD12J. Hit or slapped him/her on the hand, arm, or leg.

CD12K. Beat him/her up with an implement (hit over and over as hard as one could).

CD13. Do you believe that in order to bring up (raise, educate) (name) properly, you need to physically punish him/her?

Salt iodization module: SI

SI1. We would like to check whether the salt used in your household is iodized. May I see a sample of the salt used to cook the main meal eaten by members of your household last night?
(Note: After examining the salt circle the number that corresponds to the test result
Name of the Salt________________

Disability: DA

To be administered to caretakers of all children 2 through 9 years old living in the household. For household members below age 2 or above age 9, leave rows blank
I would like to ask you if any children in this household aged 2 through 9 has any of the health conditions I am going to mention to you.

DA1. Line no.

DA3. Compared with other children, does or did (name) have any serious delay in sitting, standing, or walking?

DA4. Compared with other children, does (name) have difficulty seeing, either in the daytime or at night?

DA5. Does (name) appear to have difficulty hearing? (uses hearing aid, hears with difficulty, completely deaf?)

DA6. When you tell (name) to do something, does he/she seem to understand what you are saying?

DA7. Does (name) have difficulty in walking or moving his/her arms or does he/she have weakness?

DA8. Does (name) sometimes have fits, become rigid, or lose consciousness?

DA9. Does (name) learn to do things like other children his/her age?

DA10. Does (name) speak at all (can he/she make him or herself understood in words; can say any recognizable words)?

DA11. (For 3-9 year olds): Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?

DA12. (For 2-year-olds): Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?

DA13. Compared with other children of the same age, does (name) appear in any way mentally backward, dull or slow?