We are from Bangladesh Bureau of Statistics. 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 one hour. 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 _ _ / _ _ / 2006

HH6. Area:

HH7. Region/Division:

HH7A. District Code

HH7B. Sub-district (Upazila) Code

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 (15-49) for interview: _ _

HH13. No. of women questionnaires (WM) completed: _ _

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

HH15. No. of under-5 questionnaires (UF) 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?

For age 5-18 years

HL13. Can the child swim?

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. Since January/06 to present, 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?

ED6C. Type of school

ED7. Did (name) attend school or preschool at any time during the January-December, 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.
WS 6_1. Have you heard of arsenic in water?

WS 6_2. What are the problem or diseases caused by arsenic contamination?
(multiple response)

WS 6_3. Are you doing anything to protect yourself from arsenic contamination? If yes, what are you doing for this? (multiple response)

WS 6_4. If it is TW, was it?s water tested for arsenic and TW marked by any color?

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

WS9A. How do you usually wash your hand after own or child?s defaecation ?

Household characteristics module: HC

HC1A. What is the religion 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:









HC11A. Did any boy/girl under 18 years of your household get injured/accident /drowned in the last one year?

HC11B. If yes, what happened to how many of them?
(write the number of cases for each item in the boxes separately for boys and girls)
(write 0 for cases no in any box)

HC11C. How is she/he now?
(write 0 for cases no in any box)

HC11D. Was there any marriage in the household in last three years? If yes, was the marriage registered?

HC15. How many years do you live in this property/land?

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.
TN3B. How much did you pay for the (name of net highest in the list of nets available in the household, in TN3) mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than one net in the same category, ask question referring to the most recently obtained net.
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? _ _

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?
Once you have examined the salt,
Circle number that corresponds to test outcome.

SI2. Does any eligible woman age 15-49 reside in the household?
Check household listing, column HL6. You should have a questionnaire with the information panel filled in for each eligible woman.
[] Yes (Go to questionnaire for individual women to administer the questionnaire to the first eligible woman)
[] No (Continue SI3)

SI3. Does any child under the age of 5 reside in the household?
Check household listing, column HL8. You should have a questionnaire with the Information Panel filled in for each eligible child.
[] Yes (Go to questionnaire for children under five to administer the questionnaire to mother or caretaker of the first eligible child.)
[] No (End the interview by thanking the respondent for his/her cooperation.
Gather together all questionnaires for this household and tally the number of interviews completed on the cover page
(HH12-15)

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)?

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