We are on behalf of ministry of health and social welfare of Republika Srpska. We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will take about 45 minutes. All the information we obtain will remain strictly confidential and your answers will never be identified. During this time I would like to speak with the household head and all mothers or others who take care of children in the household.
May I start now? If permission is given, begin the interview.

Household Information Panel: HH

HH1. Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

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

HH6. Area:

HH7. Region:

HH8. Name of head of household: ____

After all questionnaires for the household have been completed, fill in the following information:
[Note: HH9 to HH16]

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

First, please tell me the name of each person who usually lives here, starting with the head of the household.
List the head of the household in line 01. List all household members (HL2), their relationship to the household head (HL3), and their sex (HL4).
Then ask: are there any others who live here, even if they are not at home now? (These may include children in school or at work). If yes, complete listing.
Then, ask questions starting with hl5 for each person at a time. Add a continuation sheet if there are more than 15 household members.
[] Tick here if continuation sheet used

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
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

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?

Are there any other persons living here - even if they are not members of your family or do not have parents living in this household?
Including children at work or at school? If yes, insert child's name and complete form.
Then, complete the totals below.

Totals

Now for each woman age 15-49 years, write her name and line number and other identifying information in the information panel of the women's questionnaire.
For each child under age 5, write his/her name and line number and the line number of his/her mother or caretaker in the information panel of the questionnaire for children under five.
You should now have a separate questionnaire for each eligible woman and each child under five in the household.

Education Module: ED

For household members age 5 and above

ED1. Line no. _ _

ED1A. Name ____

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

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?
If "flush" or "pour flush", probe: Where does it flush to?
If necessary, ask permission to observe the facility.

WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

Household characteristics module: HC

HC1A. What is the religion of the head of this household?

HC1B. What is the mother tongue/native language of the head of this household?

HC1C. To what ethnic group does the head of this household belong?

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

HC3. Main material of the dwelling floor:
Record observation.
HC4. Main material of the roof.
Record observation.
HC5. Main material of the walls.
Record observation.
HC6. What type of fuel does your household mainly use for cooking?

HC7. In this household, is food cooked on an open fire, an open stove or a closed stove?
Probe for type.
HC7A. Does the fire/stove have a chimney or a hood?

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:








HC11. Does any member of this household own any land that can be used for agriculture?

HC12. How many hectares of agricultural land do members of this household own?
If more than 97, record '97'. If unknown, record '98'.
HC13. Does this household own any livestock, herds, or farm animals?

HC14. How many of the following animals does this household have?

Countries may add to the list of items in HC9 items of furniture (such as a table, a chair, a sofa, a bed, an armoire, or a cupboard or cabinet). In addition, each country should add at least four additional household appliances so that the list includes at least three items that even a poor household may have, at least three items that a middle income household may have, and at least three items that a high income household may have. Some possible additions are clock, water pump, grain grinder, fan, blender, water heater, electric generator, washing machine, microwave oven, computer, VCR or DVD player, cassette or CD player, camera, air conditioner or cooler, color TV, sewing machine.
Countries may add other country-specific animals, such as oxen, water buffalo, camels, llamas, alpacas, pigs, ducks, geese, or elephants to the list in HC14.

HC15A. Do you or someone in this household own this dwelling, or do you rent this dwelling?

HC15B. Do you or someone in this household have a title deed for this dwelling?

HC15C. What kind of document do you have for the ownership of this dwelling?
Anything else?
Record all items mentioned.
HC15D. Do you have a written rental contract for this dwelling?

HC15E. Do you have any documentation or agreement for the rental of this dwelling? If yes, what kind of document or agreement do you have for the rental of this dwelling? Anything else?
Record all items mentioned.
HC15F. Do you feel secure from eviction from this dwelling?

HC15G. Have you been evicted from your home at any time during the past 5 years?

HC15H. Dwelling located in or near:
Observe, and circle all items that describe the location of dwelling.
HC15I. Condition of dwelling:
Record observation. Record all that apply.
HC15J. Dwelling surroundings:
Record observation. Record all that apply.
HC16. Does this dwelling have next rooms/premises?











HC17. Does your dwelling lack adequate possibility of heating?

HC18. Which of the following statement best describes employment status of the head of this household?

Child labour module: CL

To be administered to mother/caretaker of each child in the household age 5 through 14 years. For household members below age 5 or above age 14, leave rows blank.
Now I would like to ask about any work children in this household may do.

CL1. Line no. _ _

CL2. Name: ____

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. At any time 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 household chores such as shopping, collecting firewood, cleaning, fetching water, or caring for children?

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 CD9; write down the rank number of the child and continue with CD11

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) in CD7 above. 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. This is the rank number of the child about whom the questions will be asked. Record the rank number in CD9 below. Finally, record the line number and name of the selected child in CD11 on the next page. Then, find the mother or primary caretaker of that child, and ask the questions, beginning with CD12.

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

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 name and line no. of the child selected for the module from CD3 and CD2, based on the rank number in CD9.

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. Shouted, yelled at or screamed at him/her.

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?

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.

DA2. Child's name

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 and/or stiffness in the arms or legs?

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)?