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MICS household questionnaire


We are from the National Institution for Statistics and Demographics (INSD). 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 40 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

Village / Sector _ _

HH1. Cluster number: _ _ _

HH2. Household Number _ _ _

HH2A. Region

HH2B. Province

HH2C. Department.

HH2D. Commune.

MDH: Time at beginning of interview.

Hours _ _
Minutes _ _

HH3. Interviewer name and number:

Name: ____
Number: _ _
Date ____

HH4. Name of and code of controller _ _

Name: ____
Number: _ _
Date ___

HH4A. Supervisor name and number:
Name: ____
Number: _ _
Date___
HH5. Visits of interviewers
[List interviews 1 -3]

Date:
Result
Next visit
Date ___
Time ___
Day/month/year of final interview _ _ / _ _ / _ _ _ _
Number of visits _

HH6. Area:

[] 1 Ouagadougou
[] 2 Another city
[] 3 Rural

HH7. Region:

[] 01 Boucle du Mouhoun
[] 02 Cascades
[] 03 Centre
[] 04 Centre-Sud
[] 05 Centre-Est
[] 06 Centre-Nord
[] 07 Centre-Ouest
[] 08 Est
[] 09 Hauts-Bassins
[] 10 Nord
[] 11 Plateau-Central
[] 12 Sahel
[] 13 Sud-Ouest

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:

[] 1 Completed
[] 2 Not at home
[] 3 Refused
[] 4 HH not found/destroyed
[] 6 Other (specify) ____

HH10. Respondent to HH questionnaire

Name: ____
Line No: _ _

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: _ _

Language of interview:

[] 1 French
[] 2 Mooré
[] 3 Dioula
[] 4 Fulfuldé/Peul
[] 5 Other

Was an interpreter used?

[] 1 Yes
[] 2 No

HH16. Data entry clerk: _ _

HH 16A. Office use
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: ____

HL2A. Situation of residence.

[] 1 RP = Resident Present
[] 2 RA = Resident Absent
[] 3 VI =Visitor

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

[] 01 Head
[] 02 Wife or husband
[] 03 Son or daughter
[] 04 Son or daughter in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother or sister
[] 09 Brother or sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew by blood
[] 12 Niece/nephew by marriage
[] 13 Other relative
[] 14 Adopted/foster/stepchild
[] 15 Not Related
[] 98 Don't know

HL4. Is (name) male or female?

[] 1 Male
[] 2 Female

HL5. How old is (name)? How old was (name) in his/her last birthday?
Record in Completed years
Age: _ _
[] 98 DK [See instructions: to be used only for elderly household members (code meaning "do not know/over age 50").]

HL6. Eligible for women's interview

_ _Circle line no. if woman is age 15-49

HL7A. Eligible for child discipline module
For each child age 2-14: Who is the mother or primary caretaker of this child?

_ _ Record line no. of mother/caretaker

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

_ _ Record line no. of mother/caretaker

HL8A If age 18--59. Was (name) very sick for at least 3 months of the last 12 months?

[] 1 Yes
[] 2 No
[] 8 DK

For children age 0-17 years ask HL9-HL12

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

[] 1 Yes
[] 2 No (Go to HL11)
[] 8 DK (Go to HL11)

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

_ _ Record line no. of mother or 00 for 'no'

HL 10A. If the mother doesn't live in the household: Was (name)'s mother very sick for at least 3 months of the last 12 months?

[] 1 Yes
[] 2 No
[] 8 DK

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

[] 1 Yes
[] 2 No (Go to next line)
[] 8 DK (Go to next line)

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

_ _ Record line no. of father or 00 for 'no'

HL 12A. If the father doesn't live in the household: Was (name)'s father very sick for at least 3 months of the last 12 months?

[] 1 Yes
[] 2 No
[] 8 DK

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

_ _ Women 15-49
_ _ Children 5-14
_ _ Under-5s
_ _ Very sick (=1)
_ _ Deceased mothers (=2)
_ _ Very sick mothers (=1)
_ _ Deceased fathers (=2)
_ _ Very sick fathers (=1)

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 ____

Age _ _

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

[] 1 Yes (Go to ED3)
[] 2 No (Go to next line)

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

Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Secondary - 1st round
[] 3 Secondary - 2nd round
[] 4 Higher
[] 8 DK
Grade: _ _
[] 98 DK
If less than 1 grade, enter 00.

Reference for grade codes for specific grades and classes
0 Pre-school

01 First section
02 Middle section
03 Last section

1 Primary

01 CP1
02 CP2
03 CE1
04 CE2
05 CM1
06 CM2
08 Don't know

2 Secondary - 1st round

01 6th
02 5th
03 4th
04 3rd
05 FPP
08 Don't know

3 Secondary - 2nd round

01 2nd
02 1st
03 Terminal
04 FRB
08 Don't know

4 Higher

01 1st year
02 2nd year
03 3rd year
04 4th year
05 5th year or higher
08 Don't know

[] 8 DK

Leave grade blank

For household members age 5-24 years

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

[] 1 Yes
[] 2 No (Go to ED7)

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

_ Insert number of days in space below

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

Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Secondary - 1st round
[] 3 Secondary - 2nd round
[] 4 Higher
[] 8 DK
Grade: _ _
[] 98 DK

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

[] 1 Yes
[] 2 No (Go to next line)
[] 8 No (Go to next line)

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

Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Secondary - 1st round
[] 3 Secondary - 2nd round
[] 4 Higher
[] 8 DK
Grade: _ _
[] 98 DK

Water and sanitation module: WS

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

Piped water
[] 11 Piped into dwelling (Go to WS5)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe (Go to WS3)
[] 21 Tubewell/borehole (Go to WS3)
Dug well
[] 31 Protected well (Go to WS3)
[] 32 Unprotected well (Go to WS3)
Water from spring
[] 41 Protected spring (Go to WS3)
[] 42 Unprotected spring (Go to WS3)
[] 51 Rainwater collection (Go to WS3)
[] 61 Tanker-truck (Go to WS3)
[] 71 Cart with small tank/drum (Go to WS3)
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel) (Go to WS3)
[] 91 Bottled water
[] 96 Other (specify) ____ (Go to WS3)

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

Piped water
[] 11 Piped into dwelling (Go to WS5)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe
[] 21 Tubewell/borehole
Dug well
[] 31 Protected well
[] 32 Unprotected well
Water from spring
[] 41 Protected spring
[] 42 Unprotected spring
[] 51 Rainwater collection
[] 61 Tanker-truck
[] 71 Cart with small tank/drum
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96 Other (specify) ____

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

_ _ _ No. of minutes
[] 995 Water on premises (Go to WS5)
[] 998 DK

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.

[] 1 Adult woman
[] 2 Adult man
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK

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

[] 1 Yes
[] 2 No (Go to WS7)
[] 8 DK (Go to WS7)

WS6. What do you usually do to the water to make it safer to drink?
Anything else?
Record all items mentioned.
[] A Boil
[] B Add bleach/chlorine
[] C Strain it through a cloth
[] D Use water filter (ceramic, sand, composite, etc.)
[] E Solar disinfection
[] F Let it stand and settle
[] X Other (specify) ____
[] Z DK

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.

Flush/pour flush
[] 12 Flush to septic tank
[] 13 Flush to pit (latrine)
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab / open pit
[] 95 No facilities or bush or field (Go to next module)
[] 96 Other (specify) ____

WS8. Do you share this facility with other households?

[] 1 Yes
[] 2 No (Go to next module)

WS9. How many households in total use this toilet facility

0_ No. of households (if less than 10)
[] 10 Ten or more households
[] 98 DK

Household characteristics module: HC

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

[] 1 Catholic
[] 2 Protestant
[] 3 Muslim
[] 4 Traditional/animinist
[] 6 Other religion (specify) ____

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

[] 01 Bobo/bwaba/bawmou
[] 02 Dagara
[] 03 Dioula/Bambara
[] 04 Fulfuldé
[] 05 Gourmantchéma
[] 06 Gourounsi
[] 07 Lobiri/Birifor
[] 08 Mooré
[] 09 Sénoufo
[] 10 Touareg/Bella
[] 96 Other language (specify) ____

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

[] 01 Bobo
[] 02 Dagari
[] 03 Dioula
[] 04 Fulfuldé / peulh
[] 05 Gourmantché
[] 06 Gourounsi
[] 07 Lobiri/Birifor
[] 08 Moosi
[] 09 Sénoufo
[] 10 Touareg/Bella
[] 96 Other ethnic group (specify) ____

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

No. of rooms: _ _

HC3. Main material of the dwelling floor:
Record observation.
Natural floor
[] 11 Earth/sand
[] 12 Dung
Rudimentary floor
[] 21 Wood planks
[] 22 Palm/bamboo
Finished floor
[] 31 Parquet or polished wood
[] 32 Vinyl or asphalt strips
[] 33 Ceramic tiles
[] 34 Cement
[] 35 Carpet
[] 96 Other (specify) ____

HC4. Main material of the roof.
Record observation.
Natural roofing
[] 11 No roof
[] 12 Thatch/palm leaf
Rudimentary roofing
[] 21 Rustic mat
[] 22 Palm/bamboo
Finished roofing
[] 31 Metal
[] 32 Wood
[] 33 Calamine/cement fiber
[] 34 Ceramic tiles
[] 35 Cement
[] 36 Roofing shingles
[] 96 Other (specify) ____

HC5. Main material of the walls.
Record observation.
Natural walls
[] 11 No walls
[] 12 Cane/palm/trunks
[] 13 Dirt
14 Bricks
15. Straw
Rudimentary walls
[] 21 Stone with mud
[] 22 Plywood
[] 23 Carton
[] 24 Bricks in "banco" with mud
25 Bricks in "banco" with cement
Finished walls
[] 31 Cement
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement blocks
[] 96 Other (specify) ____

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

[] 01 Electricity (Go to HC8)
[] 02 Liquid propane gas (LPG) (Go to HC8)
[] 03 Natural gas (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 10 Animal dung
[] 11 Agricultural crop residue
12 Petrol (Go to HC8)
[] 96 Other (specify) ____

HC7. In this household, is food cooked on an open fire, an open stove or a closed stove?
Probe for type.
[] 1 Open fire
[] 2 Open stove
[] 3 Closed stove (Go to HC8)
[] 6 Other (specify) ____ (Go to HC8)

HC7A. Does the fire/stove have a chimney or a hood?

[] 1 Yes
[] 2 No

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

[] 1 In the house
[] 2 In a separate building
[] 3 Outdoors
[] 6 Other (specify) ____

HC9. Does your household have:

Electricity?
[] 1 Yes
[] 2 No

A radio?
[] 1 Yes
[] 2 No

A television?
[] 1 Yes
[] 2 No

A mobile telephone?
[] 1 Yes
[] 2 No

A non-mobile telephone?
[] 1 Yes
[] 2 No

A refrigerator?
[] 1 Yes
[] 2 No

HC10. Does any member of your household own:

A watch?
[] 1 Yes
[] 2 No

A bicycle?
[] 1 Yes
[] 2 No

A motorcycle or scooter?
[] 1 Yes
[] 2 No

An animal drawn cart?
[] 1 Yes
[] 2 No

A car or truck?
[] 1 Yes
[] 2 No

HC11. Does any member of this household own any land that can be used for agriculture?
[This question is from optional modules]

[] 1 Yes
[] 2 No (Go to HC13)

HC12. How many hectares of agricultural land do members of this household own?
[This question is from optional modules]
If more than 97, record '97'. If unknown, record '98'.
Hectares _ _

HL12A. Is the harvest and production that comes from this land sufficient for the annual needs of your household?

[] 1 Yes (Go to HC13)
[] 2 No
[] 3 Harvest isn't consumed by household (Go to HC13)
[] 8 DK

HC12B. What is the number of months that is covered by your harvest/your crops?

_ _ No of months
[] 98 DK

HC13. Does this household own any livestock, herds, or farm animals?
[This question is from optional modules]
[] 1 Yes
[] 2 No (Go to next module)

HC14. How many of the following animals does this household have?
[This question is from optional modules]
If none, record '00'. If more than 97, record '97'. If unknown, record '98'.

Milk cows or bulls?
Milk cows or bulls _ _

Horses, donkeys, or mules?
Horses, donkeys, or mules _ _

Goats?
Goats _ _

Sheep?
Sheep _ _

Chickens?
Chickens _ _

Guinea waterfowl? _ _

Other (specify) ____ _ _

Pigs?
Pigs _ _

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

[] 1 Own
[] 2 Rent (Go to HC15D)
[] 3 Rent free/squatter/other (Go to HC15D)

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

[] 1 Yes (Go to HC15F)
[] 2 No

HC15C. What kind of document do you have for the ownership of this dwelling?
Anything else?
Record all items mentioned.
[] A Certificate of occupation (or adjudication certificate) (Go to HC15F)
[] B Property tax certification (Go to HC15F)
[] C Utility bills (Go to HC15F)
[] E. Certificate of allocation (Go to HC15F)
[] X Other (specify) ____ (Go to HC15F)
[] Y None/No document (Go to HC15F)

HC15D. Do you have a written rental contract for this dwelling?

[] 1 Yes (Go to HC15F)
[] 2 No

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.
[] A Informal agreement (written)
[] B Verbal agreement (no document)
Occupied rent free
[] C With knowledge of owner
[] D Without knowledge of owner
[] X Other (specify) ____
[] Y None/no document

HC15F. Do you feel secure from eviction from this dwelling?

[] 1 Yes
[] 2 No
[] 8 DK

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

[] 1 Yes
[] 2 No

HC15H. Dwelling located in or near:
Observe, and circle all items that describe the location of dwelling.
[] A Landslide area
[] B Flood-prone area
[] C River bank
[] D Steep hill
[] E Garbage mountain / pile
[] F Industrial pollution area
[] G Railroad
[] H Power plant
[] I Flyover
[] Y None of the above

HC15I. Condition of dwelling:
Record observation. Record all that apply.
[] A Cracks/openings in walls
[] B No windows
[] C Windows with broken glass/no glass
[] D Visible holes in the roof
[] E Incomplete roof
[] F Insecure door
[] Y None of the above

HC15J. Dwelling surroundings:
Record observation. Record all that apply.
[] A Very narrow passage between houses instead of road
[] B Too many power cables connecting to neighborhood's main distribution post
[] Y None of the above

Source and cost of supplies for insecticide-treated mosquito nets

TN1. In your household, do you have mosquito netting you can use for sleeping?

[] 1 Yes
[] 2 No (Go to next module)

TN2. How many mosquito nets do you have in your household? If more than 7, record 7.

No of nets __

TN3. Is the mosquito net (regardless of which one) one of the following brands?
Read the name of each brand, show an image, and circle the codes Yes or No for each brand. If possible, ask the respondent to show you the net to double check the brand.
Permanent mosquito netting:

TN3L1. Permanent?
TN3L2. Olyset?
TN3L3. Serena?

Other mosquito nets:

TN3O1. Retreated mosquito nets?
TN3O2. Ordinary mosquito nets?
TN3O3. Another brand of any mosquito net?
TN304. Another unknown mark of mosquito netting?

TN3A. Where did you get 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.
Public sector
[] 11 Govt. hospital
[] 12 Govt. health centre
[] 13 CSPS
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
Private medical sector
[] 21 Private hospital/clinic
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
Other source
[] 31 Relative or friend
[] 32 Shop
[] 33 Kiosk
34 Bar / nightclub
35 Hotel
36 Traveling vendor
[] 96 Other (specify) ____
[] 98 DK

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.
_ _ _ _ CFA Francs
[] 9996 Free
[] 9998 DK

TN4. Verify TN3 for the type of mosquito net(s). Check the corresponding box below and follow the instructions below:

[] 1 If yes for "permanent mosquito net" (Permanet, Olyset or Serena) go to the next module.
[] 2 If yes for "treated mosquito net" go to TN6.
[] 3 If yes for "other mosquito net" (another brand or an unknown brand), continue with TN5.

TN5. When you acquired your newest mosquito net, was it treated with an insecticide to kill or repel mosquitos?

[] 1 Yes
[] 2 No
[] 8 DK

TN6. How long have you owned the most recently obtained mosquito net?
If less than one month, record '00.'
If the response is "12 months" or "1 year," probe to determine if the mosquito net was obtained exactly 12 months ago, earlier, or later.

Months ? _ _
[] 95 More than 24 months ? 95
[] DK/Not sure

TN7. Since you've had mosquito netting, have you treated them or dipped them in a liquid that kills or repels mosquitos?

[] 1 Yes
[] 2 No (Go to next module)
[] 8 DK(Go to next module)

TN8. HOW LONG HAS IT BEEN SINCE THE NET WAS LAST SOAKED OR DIPPED IN INSECTICIDE?
If less than one month, record '00.'
If the response is "12 months" or "1 year," probe to determine if the mosquito net was obtained exactly 12 months ago, earlier, or later.

Months ? _ _
[] 95 More than 24 months ?
[] DK/Not sure

Children made vulnerable and orphaned by AIDS (OV)

OV1. Verify HL5: Are there any children aged 0-17?

[] Yes, continue with OV2
[] No, go to next module

OV2. I would like you to think about the last 12 months. Did a member of your household pass away in the last twelve months?

[] 1 Yes
[] 2 No (Go to OV5)

OV3. For those who passed away in the last 12 months, were any of them between 18-59 years old?

[] 1 Yes
[] 2 No (Go to OV5)

OV4. For those who passed away in the last 12 months and were aged 18-59 years old: were any of them extremely sick for at least 3 months of the 12 months prior to their death?

[] 1 Yes(Go to OV8)
[] 2 No

OV5. Return to the HH table and check the following:

[] 1 Verify the totals of HL8A., HL9 and HL11
[] At least one deceased mother or father (Go to OV8)
[] No deceased mother or father
[] 2 Check the totals for HL8A.
[] At least one adult aged 18-59 was very sick for at least 3 months of the past 12 months (Go to OV8)
[]No adults aged 18-59 were very sick for at least 3 months of the past 12 months.
[] 3 Verify the totals for HL10A and HL12A.
[] At least one mother or father were sick for at least 3 months of the last 12 months. (Go to OV8)
[] No mother nor father were sick for at least 3 months of the last 12 months. (Go to next module)

OV8. List all children ages 0-17. Record the names, line numbers, and ages of all children,
starting with the first child, and continue in the order in which they are listed in the
household registration module. Use an additional questionnaire if there are more than 4 children aged 0-17 in the household.
in the household. Ask any questions for one child before moving on to the next child.

1st child
[Repeat for up to 5 children]

Name (from HL2) _____
Line number (from HL1) _ _
Age (from HL5) _ _

OV9. I would like to ask you about any type of assistance or organized support your household may have received for (NAME) for which you did not pay. Household may have received for (NAME) that you did not pay for. By organized help or support, I mean support provided by someone who works for a program, whether it be government private sector, religious, charitable or community-based program. It is important to remember that this is support for which you have not paid.
[The answers for OV10-OV18 are all a continuation of children table 1-5 as listed in question above.]
OV10. I would now like to ask you questions about the support your household has received for (name). in the past 12 months, did your household months, has your household received medical support for (name), such as care, supplies or medicines?

[] 1 Yes
[] 2 No
[] 8 DK

OV11. In the last 12 months months, did your household receive moral or psychological support for (name) such as companionship, advice advice from a counselor, counseling, or spiritual support?

[] 1 Yes
[] 2 No (Go to OV813
[] 8 DK(Go to OV13)

OV12. Did your household receive any type of these supports in the last 3 months?

[] 1 Yes
[] 2 No (Go to OV13
[] 8 DK(Go to OV13)

OV13. In the last 12 months, did your house receive any material support for (name) such as clothes, food, or financial support?

[] 1 Yes
[] 2 No (Go to OV13
[] 8 DK(Go to OV13)

OV14. Did your household receive any type of these supports in the last 3 months?

[] 1 Yes
[] 2 No
[] 8 DK

OV15. In the last 12 months, did your household receive social support for (name) such as help around the house, training to provide caregiving or assistance for administrative procedures?

[] 1 Yes
[] 2 No (Go to OV17)
[] 8 DK(Go to OV17)

OV16. Did your household receive any type of support in the last 3 months?

[] 1 Yes
[] 2 No
[] 8 DK

OV17. Verify OV8, the age of the child.

[] Age 0-3 (Go to next child)
[] Age 5-17 (Go to OV18)

OV18. In the last 12 months, did your household receive support for schooling from (name) as a scholarship, free tuition, books or books or supplies?

[] 1 Yes
[] 2 No
[] 8 DK

Child discipline module: CD

CD0. Verify HL5. Is there a child between 2-14 years old?

[] No (Go to next module)
[] Yes (Go to CD1)

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.

[] Line 01-08

CD2. Line no. from HL1.

Line _ _

CD3. Name from HL2.

Name ____

CD4. Sex from HL4.

[] 1 M
[] 2 F

CD5. Age from HL5.

Age _ _

CD6. Line no. of mother/caretaker from HL7A.

Mother _ _

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

Rank number of 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.

____ Name
_ _ Line number

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.

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

CD12C. Shook him/her.

[] 1 Yes
[] 2 No

CD12D. Shouted, yelled at or screamed at him/her.

[] 1 Yes
[] 2 No

CD12E. Gave him/her something else to do.

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No
[] 8 Don't know/no opinion

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.

[] 1 Not iodized 0 PPM
[] 2 Less than 15 PPM
[] 3 15 PPM or more
[] 6 No salt in home
[] 7 Salt not tested

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. 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.)