MICS Household Questionnaire

Bhutan Multiple Indicator Survey (BMIS)
Household Information Panel: HH

HH1. Block/chiwog name and code: ____ __ _ _

HH1A. Gewog/town name and code: ____ _ _


HH2. Household serial number: _ _

HH3. Interviewer name and number

HH4. Supervisor name and number:

HH5. Day/month/year of interview

HH6. Area

HH7. Dzongkhag name and code:

HH7: Code for Dzongkhags:

We are from National Statistics Bureau. We are conducting a survey on the situation of household, women and children. I would like to talk to you about these subjects. The interview might take about 30 minutes. All the information we obtain will remain strictly confidential while your participation is voluntary it is of utmost importance that you respond to the survey as the results will help the government in planning and decision making. If you have no objection, may I start now?

After all questionnaires for the household have been completed, fill in the following information:
[Note: for question HH8 to HH18]

HH8. Name of head of household: ____

HH9. Status of household questionnaire:

HH10. Respondent to household questionnaire:

HH11. Total number of household members: _ _

HH12. Number of women age 15-49 years: _ _

HH13. Number of woman's questionnaires completed: _ _

HH14. Number of children under age 5: _ _

HH15. Number of under-5 questionnaires completed: _ _

HH16. Field edited by (name and number)

HH17. Date entry keyer (name and number)

HH18. Record the starting time (24 hours)

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?
If yes, complete listing for questions HL2-HL4. Then, ask questions starting with HL5 for each person at a time.
Use an additional questionnaire if all rows in the household listing form have been used.

HL1. SL. no.: _ _

HL2. Name: ____

HL3. What is the relation-ship of (name) to the head of household?

HL4. Is (name) male or female?

HL5. What is (name's) month and year of birth?

HL6. How old is (name)?
Record in completed years. If age is 95 or above, record '95'
HL7. Circle SL no.
If woman is age 15-49 (for woman age 15-49)

HL8. Who is the mother or primary caretaker of this child?
Record SL no. of mother/caretaker (for children age 2-17.)
HL9. Who is the mother or primary caretaker of this child?
Record SL no. of mother/ caretaker (for children under age 5)
HL10. Did (name) stay here last night?

For children age 0-17 years [HL11 to HL14]

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

HL12. Does (name's) natural mother live in this household?
Record SL. no. of mother or 00 for no
HL13. Is (name's) natural father alive?

HL14. Does (name's) natural father live in this household?
Record SL. no. of father or 00 for "no"
[] tick here is additional household listing sheet used.
Probe for additional household members. Probe especially for any infants or small children not listed, and others who may not be members of the family (such as servants, friends) but who usually live in the household. Insert names of additional members in the household list and complete form accordingly.
Now for each woman age 15-49 years, write her name and serial number and other identifying information in the information panel of a separate individual women's questionnaire. For each child under age 5, write his/her name and serial number and the serial number of his/her mother or caretaker in the information panel of a separate Under-5 questionnaire. You should now have a separate questionnaire for each eligible woman and each child under five in the household.

Codes for HL3. Relationship to head of household

Education: ED

For household member age 4 and above [ED1 to ED4]

ED1. SL no: _ _

ED2. Name and age
Copy from Household Listing Form, HL2 and HL6
ED2A. Has (name) ever attended non formal or monastic education?
If "yes": NFE, monastic or both?

ED3. Has (name) ever attended school or pre-school?

ED4. What is the highest level of school (name) attended? What is the highest grade (name) completed at this level?
If less than a full grade then, enter 17
For household members age 4-24 years [ED5 to ED8]

ED5. During the (2009-2010) school year, did (name) attend school or preschool at any time?

ED5A. Is name attending in or outside Bhutan?

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

ED7. During the previous school year, that is (2008-2009), did (name) attend school or preschool at any time?

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

Water and Sanitation: 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. Where is that water source located?

WS4. How long does it take to go there, get water, and come back?

WS5. Who usually goes to this source to collect the water for your household?
Probe: Is this person under age 15? What sex?

WS6. Do you do anything to the water to make it safer to drink?

WS7. What do you usually do to make the water safer to drink?
Probe: Anything else? Record all items mentioned.
WS8. 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.
WS9. Do you share this facility with others who are not members of your household?

WS10. Do you share this facility only with members of other households that you know, or is the facility open to the use of the general public?

WS11. How many households in total use this toilet facility, including your own household?

Household characteristics: HC

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

HC2A. How many rooms are there in this dwelling unit?
(Exclude toilet and kitchen)
HC3. Main material of the dwelling floor
Record observation
HC4. Main material of the roof
Record observation
HC5. Main material of the exterior walls.
Record observation
HC6. What type of fuel does your household mainly use for cooking?

HC7. Is the cooking usually done in the house, in a separate building, or outdoors?
If 'In the house', probe: is it done in a separate room used as a kitchen?

HC8. Does your household have:

A. Electricity?

B. A radio?

C. A television?

D. A fixed telephone?

E. A refrigerator?

F. A sofa set?

G. A washing machine?

H. A sewing machine?

I. A power-tiller?

J. A vaccum cleaner?

K. A rice cooker?

HC9. Does any member of your household own:

A. A wrist watch?

B. A mobile phone?

C. A bicycle?

D. A motorcycle or scooter?

E. A car or truck?

F. A computer?

G. A foreign bow?

H. A camera?

I. A VCR/VCD/DVD player?

J. A sersho gho/kira?

HC10. Do you or someone living in this household own this dwelling?
If "No", then ask: Do you rent this dwelling for pay or are you living there rent free? If "Rented from someone else for pay", circle "2". If it is ?rent free?, circle ?3?. For other responses, circle "6".
HC11. Does any member of this household own any land that can be used for agriculture?

HC12. How many acres/decimals of agricultural land do members of this household own?
If less than one acre, record "00" followed by the number of decimals. If 95 or more, record '95.00'. If acre not known, record '99.98'.
HC13. Does this household own any livestock, herds, other farm animals, or poultry?

HC14. How many of the following animals does this household have?
If none, record '00'. If 95 or more, record '95'. If unknown, record '98'.

A. Cattle?

B. Horses, donkeys, or mules?

C. Goats?

D. Sheep?

E. Chickens?

F. Pigs?

G. Buffalo?

H. Yaks?

HC15. Does any member of this household have a bank account?

HC16. Now I would like to talk about food security.
In the last 12 months has a situation been faced when there was not enough food to feed all members of the household?

HC17. In what month(s) did you experience this situation?
Circle all that apply.
Child Labour: CL

To be administered for children in the household age 5-17 years. For household members below age 5 or above age 17, leave rows blank.
Now I would like to ask about any work children in this household may do.

CL1. SL. no.: _ _

CL2. Name and age copy from Household Listing Form, HL2 and HL6

CL3. During the past week, 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?
CL4. 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?
If more than one job, include all hours at all jobs.
CL5. During the past week, did (name) fetch water or collect firewood for household use?

CL6. Since last (day of the week), about how many hours did he/she fetch water or collect firewood for household use?

CL7. During the past week, did (name) do any paid or unpaid work on a family farm or in a family business or selling goods in the street?
Include work for a business run by the child, alone or with one or more partners.
CL8. Since last (day of the week), about how many hours did he/she do this work for his/her family or himself/herself?

CL9. During the past week, did (name) help with household chores such as shopping, cleaning, washing clothes, cooking; or caring for children, old or sick people?

CL10. Since last (day of the week), about how many hours did he/she spend doing these chores?

Disability: DA

To be administered to mothers/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 health conditions I am going to mention to you.

DA1. SL. no.: _ _

DA2. Child's name copy from Household Listing Form, HL2

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. Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?
(For 3-9 year olds):
DA12. Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?
(For 2-year-olds):
DA13. Compared with other children of the same age, does (name) appear in any way mentally backward dull, or slow?

Hand washing: HW

HW1. Please show me where members of your household most often wash their hands.

HW2. Observe presence of water at the specific place for handwashing.
Verify by checking the tap/pump, or basin, bucket, water container or similar objects for presence of water.
HW3. Record if soap or detergent is present at the specific place for handwashing.
Circle all that apply.
HW4. Do you have any soap or detergent (or other locally used cleansing agent) in your household for washing hands?

HW5. Can you please show it to me?
Record observation. Circle all that apply.
HH19. Record the end time (24 hours)

HH20. Does any eligible woman age 15-49 reside in the household?
Check household listing, column HL7 for any eligible woman. You should have a questionnaire with the information panel filled in for each eligible woman.
HH21. Does any child under the age of 5 reside in the household?
Check household listing, column HL9 for any eligible child under age 5. You should have a questionnaire with the information panel filled in for each eligible child.

Gather together all questionnaires for this household and complete the relevant information on the cover page.

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ________