MICS 6: Household Questionnaire
Belarus, 2019
Household Information Panel: HH
HH1. Cluster number: _ _ _
HH2. Household number: _ _
HH3. Interviewer name and number:
Name ____
Number _ _
Number _ _
HH4. Supervisor name and number:
Name ____
Number _ _
Number _ _
HH5. Day/Month/Year of interview:
_ _/_ _ /2019
HH6. Area
[] 1 Urban
[] 2 Rural
[] 2 Rural
HH7. Region
[] 1 Brest
[] 2 Vitebsk
[] 3 Gomel
[] 4 Grodno
[] 5 Minsk City
[] 6 Minsk
[] 7 Mogilev
[] 2 Vitebsk
[] 3 Gomel
[] 4 Grodno
[] 5 Minsk City
[] 6 Minsk
[] 7 Mogilev
HH8. Is the household selected for questionnaire for men?
[] 1 Yes
[] 2 No
[] 2 No
HH11. Record the time.
_ _ Hour
_ _ Minutes
_ _ Minutes
HH12. I am from Main Statistical Department of (city Minsk, region). We are conducting a survey in the Republic of Belarus about the situation of children and women. In this regard I would like to ask you a few questions. This interview usually takes about 25 minutes. All the information we obtain will remain strictly confidential and will only be used for statistical purposes. If you do not wish to answer a question or stop the interview, please let me know. May I start now?
[] Yes (List of household members)
[] No/not asked (Go to HH46)
[] No/not asked (Go to HH46)
HH46. Result of household questionnaire interview:
Discuss any result not completed with supervisor.
[] 01 Completed
[] 02 No household member or no competent respondent at home at time of visit
[] 03 Entire household absent for extended period of time
[] 04 Refused
[] 05 Dwelling vacant or address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
[] 02 No household member or no competent respondent at home at time of visit
[] 03 Entire household absent for extended period of time
[] 04 Refused
[] 05 Dwelling vacant or address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
HH47. Name and line number of the respondent to household questionnaire interview:
Name ____
Number _ _
Number _ _
To be filled after the Household Questionnaire is completed
Total number
HH48. Household members: __ __
HH49. Women age 15-49: __ __
HH50. If household is selected for questionnaire for men:
Men age 15-49: __ __
HH51. Children under age 5: __ __
HH52. Children age 5-17: __ __
To be filled after all the questionnaires are completed
Completed number
HH53. Women age 15-49: __ __
HH54. If household is selected for questionnaire for men (men age 15-49): __ __
HH55. Children under age 5: __ __
HH56. Children age 5-17
[] 0 Zero
[] 1 One
[] 1 One
[page 2]
List Of Household Members: HL
First, please tell me the name of each person who usually lives here, starting with the head of the household.
Write name of household head in row 01. Record names of all household members (HL2), relationship with household head (HL3) and their sex (HL4). Then ask if there are any other persons living at this address, even if they are not home now? If "yes", record details for them at HL2-HL4. Then, ask questions HL5-HL20 for each member one at a time. If additional questionnaires are used, indicate by ticking this box: ____
HL1. Line number: _ _
HL2. Name
Name: ____
HL3. What is the relationship of (name) to (name of the head of household)?
See the codes below.
Relation: _ _
HL4. Sex?
[] 1 Male
[] 2 Female
[] 2 Female
HL5. What is (name)'s date of birth?
Month: _ _
[] 98 DK
Year: _ _ _ _
[] 9988 DK
[] 98 DK
Year: _ _ _ _
[] 9988 DK
HL6. How old is (name)?
Record in completed years. If age is 95 or above, record "95".
Age _ _
HL8. Record line number if woman and age 15-49: _ _
HL9. Record line number if man, age 15-49 and HH8 is yes: _ _
HL10. Record line number if age 0-4: _ _
HL11. Age of household member 0-17?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
HL12. Is (name)"s natural mother alive?
[] 1 Yes
[] 2 No (Go to HL16)
[] 8 DK (Go to HL16)
[] 2 No (Go to HL16)
[] 8 DK (Go to HL16)
HL13. Does (name)'s natural mother live in this household?
[] 1 Yes
[] 2 No (Go to HL15)
[] 2 No (Go to HL15)
HL14. Record the line number of mother and go to HL16: _ _
HL15. Where does (name)'s natural mother live?
[] 1 Abroad
[] 2 In another household in the same region (Minsk City)
[] 3 In another household in another region (Minsk City)
[] 4 Institution in Belarus
[] 8 DK
[] 2 In another household in the same region (Minsk City)
[] 3 In another household in another region (Minsk City)
[] 4 Institution in Belarus
[] 8 DK
HL16. Is (name)'s natural father alive?
[] 1 Yes
[] 2 No (Go to HL20)
[] 8 DK (Go to HL20)
[] 2 No (Go to HL20)
[] 8 DK (Go to HL20)
HL17. Does (name)'s natural father live in this household?
[] 1 Yes
[] 2 No (go to HL19)
[] 2 No (go to HL19)
HL18. Record the line number of father and go to HL20: _ _
HL19. Where does (name)'s natural father live?
[] 1 Abroad
[] 2 In another household in the same region (Minsk City)
[] 3 In another household in another region (Minsk City)
[] 4 Institution in Belarus
[] 8 DK
[] 2 In another household in the same region (Minsk City)
[] 3 In another household in another region (Minsk City)
[] 4 Institution in Belarus
[] 8 DK
HL20. Copy the line number of mother from HL14. If blank, ask: Who is the primary caretaker of (name)?
If "No one" for a child age 15-17, record "90".
Number: _ _
Code for HL3. Relationship to head of household
[] 01 Head
[] 02 Wife/husband
[] 03 Son/daughter
[] 04 Son-in-law/daughter-in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother/sister
[] 09 Brother-in-law/sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew
[] 12 Other Relative
[] 13 Adopted/foster/stepchild
[] 96 Other (not related, servant)
[] 98 Don't Know
[] 02 Wife/husband
[] 03 Son/daughter
[] 04 Son-in-law/daughter-in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother/sister
[] 09 Brother-in-law/sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew
[] 12 Other Relative
[] 13 Adopted/foster/stepchild
[] 96 Other (not related, servant)
[] 98 Don't Know
[page 3]
Education 1: ED
ED1. Line number: _ _
ED2. Name and age
Copy HL2 and HL6 from list of household members.
Name: ____
Age: _ _
Age: _ _
ED3. Age 3 or above?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
ED4. Has (name) ever attended any educational institution, including preschool?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
ED5. What is the highest level and grade or year of school (name) has ever attended?
Level
[] 0 Preschool (Go to ED7)
[] 1 Primary
[] 2 General basic
[] 3 General secondary
[] 4 Vocational technical
[] 5 Secondary specialized
[] 6 Higher
[] 7 Postgraduate
[] 8 DK
[] 1 Primary
[] 2 General basic
[] 3 General secondary
[] 4 Vocational technical
[] 5 Secondary specialized
[] 6 Higher
[] 7 Postgraduate
[] 8 DK
Grade/year:
[] 98. DK (Go to ED7)
ED6. Did (name) ever complete that (grade/year)?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
ED7. Age 3-24?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
ED8. Check ED4: Ever attended any educational institution, including preschool?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
[page 4]
Education 2: ED
ED1. Line number _ _
ED2. Name and age
Name: ____
Age: _ _
Age: _ _
ED9. At any time during the 2018/2019 school year did (name) attend any educational institution, including preschool?
[] 1 Yes
[] 2 No (Go to ED15)
[] 2 No (Go to ED15)
ED10. During this 2018/2019 school year, which level and grade or year is (name) attending?
Level
[] 0 Preschool (Go to ED15)
[] 1 Primary
[] 3 General secondary
[] 4 Vocational technical
[] 5 Secondary specialized
[] 6 Higher
[] 7 Postgraduate
[] 8 DK
[] 1 Primary
[] 3 General secondary
[] 4 Vocational technical
[] 5 Secondary specialized
[] 6 Higher
[] 7 Postgraduate
[] 8 DK
Grade/year:
[] 98. DK
ED11. Is (he/she) attending a public or private educational institution?
[] 1 Govt/public
[] 3 Private
[] 6 Other
[] 8 DK
[] 3 Private
[] 6 Other
[] 8 DK
ED11A. Is (name) getting paid education?
[] 1 Yes
[] 2 No (Go to ED14)
[] 8 DK (Go to ED14)
[] 2 No (Go to ED14)
[] 8 DK (Go to ED14)
ED12. In the 2018/2019 school year, has (name) received any school tuition support?
If "Yes", probe to ensure that support was not received from family, other relatives, friends or neighbours.
[] 1 Yes
[] 2 No (Go to ED14)
[] 8 DK (Go to ED14)
[] 2 No (Go to ED14)
[] 8 DK (Go to ED14)
ED13. Who provided the tuition support?
[] A Govt/public
[] C Private
[] X Other
[] Z DK
[] C Private
[] X Other
[] Z DK
ED14. For the 2018/2019 school year, has (name) received any material support or cash to buy shoes, exercise books, notebooks, school uniforms or other school supplies?
If "Yes", probe to ensure that support was not received from family, other relatives, friends or neighbours.
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
ED15. At any time during the 2017/2018 school year did (name) attend any educational institution including preschool?
[] 1 Yes
[] 2 No (Go to next line)
[] 8 DK (Go to next line)
[] 2 No (Go to next line)
[] 8 DK (Go to next line)
ED16. During 2017/2018 year, which level and grade or year did (name) attend?
Level
[] 0 Preschool
[] 1 Primary
[] 3 General secondary
[] 4 Vocational technical
[] 5 Secondary specialized
[] 6 Higher
[] 7 Postgraduate
[] 8 DK
[] 1 Primary
[] 3 General secondary
[] 4 Vocational technical
[] 5 Secondary specialized
[] 6 Higher
[] 7 Postgraduate
[] 8 DK
Grade/Year:
[] 98. DK
[page 5]
Social Transfers: ST
ST1. I would like to ask you about various types of social assistance and support for families provided by the government various organizations including religious, charitable, or community-based organizations. This excludes support from family, other relatives, friends or neighbours.
Ask questions ST2-ST4 for each type of assistance (columns A-X)
ST2. Are you aware of (name of programme)?
A. Government targeted social assistance?
[] 1 Yes
[] 2 No (Go to B)
[] 2 No (Go to B)
B. Allowance for families raising children (except allowance for families raising children with disabilities under 18)?
[] 1 Yes
[] 2 No (Go to C)
[] 2 No (Go to C)
C. Allowance for families raising children with disabilities under 18?
[] 1 Yes
[] 2 No (Go to D)
[] 2 No (Go to D)
D. Pension: Retirement pension (old-age pension, disability pension, survivor's pension, pension for years of service, pension for special services to the republic), social pension?
[] 1 Yes
[] 2 No (Go to X)
[] 2 No (Go to X)
X. Any other social assistance and support provided by the government, religious, charitable, community-based or other organizations?
[] 1 Yes (specify) ____
[] 2 No (Go to HC3)
[] 2 No (Go to HC3)
ST3. Has your household or anyone in your household received assistance through (name of programme)?
A. Government targeted social assistance?
[] 1 Yes (Go to ST4)
[] 2 No (Go to B)
[] 8 DK (Go to B)
[] 2 No (Go to B)
[] 8 DK (Go to B)
B. Allowance for families raising children (except allowance for families raising children with disabilities under 18)?
[] 1 Yes (Go to ST4)
[] 2 No (Go to C)
[] 8 DK (Go to C)
[] 2 No (Go to C)
[] 8 DK (Go to C)
C. Allowance for families raising children with disabilities under 18?
[] 1 Yes (Go to ST4)
[] 2 No (Go to D)
[] 8 DK (Go to D)
[] 2 No (Go to D)
[] 8 DK (Go to D)
D. Pension: Retirement pension (old-age pension, disability pension, survivor's pension, pension for years of service, pension for special services to the republic), social pension?
[] 1 Yes (Go to ST4)
[] 2 No (Go to X)
[] 8 DK (Go to X)
[] 2 No (Go to X)
[] 8 DK (Go to X)
X. Any other social assistance and support provided by the government, religious, charitable, community-based or other organizations?
[] 1 Yes (Go to ST4)
[] 2 No (Go to HC3)
[] 8 DK (Go to HC3)
[] 2 No (Go to HC3)
[] 8 DK (Go to HC3)
ST4. When was the last time your household or anyone in your household received assistance through (name of programme)?
If less than one month, record "1" and record "00" in Months. If less than 12 months, record "1" and record in Months. If 1 year/12 months or more, record "2" and record in Years.
A. Government targeted social assistance?
[] 1 Months ago _ _ (Go to B)
[] 2 Years ago_ _ (Go to B)
[] 998 DK (Go to B)
[] 2 Years ago_ _ (Go to B)
[] 998 DK (Go to B)
B. Allowance for families raising children (except allowance for families raising children with disabilities under 18)?
[] 1 Months ago _ _ (Go to C)
[] 2 Years ago_ _ (Go to C)
[] 998 DK (Go to C)
[] 2 Years ago_ _ (Go to C)
[] 998 DK (Go to C)
C. Allowance for families raising children with disabilities under 18?
[] 1 Months ago _ _ (Go to D)
[] 2 Years ago_ _ (Go to D)
[] 998 DK (Go to D)
[] 2 Years ago_ _ (Go to D)
[] 998 DK (Go to D)
D. Pension: Retirement pension (old-age pension, disability pension, survivor's pension, pension for years of service, pension for special services to the republic), social pension?
[] 1 Months ago _ _ (Go to X)
[] 2 Years ago_ _ (Go to X)
[] 998 DK (Go to X)
[] 2 Years ago_ _ (Go to X)
[] 998 DK (Go to X)
X. Any other social assistance and support provided by the government, religious, charitable, community-based or other organizations?
[] 1 Months ago _ _ (Go to HC3)
[] 2 Years ago_ _ (Go to HC3)
[] 998 DK (Go to HC3)
[] 2 Years ago_ _ (Go to HC3)
[] 998 DK (Go to HC3)
Household Characteristics: HC
HC3. How many rooms do members of this household usually use for sleeping?
_ _ Number of rooms
HC4. Main material of the dwelling floor.
Record the code of the main floor material. If observation is not possible, ask the respondent to determine the material of the dwelling floor.
[] 31 Parquet or polished wood
[] 32 Vinyl or asphalt strips
[] 33 Ceramic Tiles
[] 34 Cement
[] 35 Carpet
[] 36 Laminat
[] 37 Finished wood planks
[] 38 Wooden particle board
[] 96 Other (specify) ____
[] 32 Vinyl or asphalt strips
[] 33 Ceramic Tiles
[] 34 Cement
[] 35 Carpet
[] 36 Laminat
[] 37 Finished wood planks
[] 38 Wooden particle board
[] 96 Other (specify) ____
[page 6]
HC5. Main material of the roof.
Record observation.
[] 31 Metal
[] 32 Wood
[] 34 Ceramic tiles
[] 37 Roofing slate
[] 38 Ruberoid
[] 96 Other (specify) ____
[] 32 Wood
[] 34 Ceramic tiles
[] 37 Roofing slate
[] 38 Ruberoid
[] 96 Other (specify) ____
HC6. Main material of the exterior walls.
Record observation.
[] 33 Bricks
[] 34 Cement Blocks
[] 35 Covered bricks, blocks
[] 36 Wood
[] 37 Plastic panels
[] 38 Concrete, reinforced concrete
[] 96 Other (specify) ____
[] 34 Cement Blocks
[] 35 Covered bricks, blocks
[] 36 Wood
[] 37 Plastic panels
[] 38 Concrete, reinforced concrete
[] 96 Other (specify) ____
HC8. Does your household have electricity?
If yes ask: Is your household connected to interconnected grid, generator, or any other isolated source of electricity?
[] 1 Yes, Interconnected gird
[] 2 Yes, off-grid (generator/isolated system)
[] 3 No (Go to HC10)
[] 2 Yes, off-grid (generator/isolated system)
[] 3 No (Go to HC10)
[page 7]
HC9. Does your household have:
A. A television?
[] 1 Yes
[] 2 No
[] 2 No
B. A refrigerator?
[] 1 Yes
[] 2 No
[] 2 No
C. A freezer?
[] 1 Yes
[] 2 No
[] 2 No
D. A vacuum cleaner?
[] 1 Yes
[] 2 No
[] 2 No
E. A microwave?
[] 1 Yes
[] 2 No
[] 2 No
F. A washing machine?
[] 1 Yes
[] 2 No
[] 2 No
G. A dishwasher?
[] 1 Yes
[] 2 No
[] 2 No
H. A fixed telephone line?
[] 1 Yes
[] 2 No
[] 2 No
HC10. Does any member of your household own:
B. A bicycle?
[] 1 Yes
[] 2 No
[] 2 No
C. A motorcycle or scooter?
[] 1 Yes
[] 2 No
[] 2 No
D. An animal-drawn cart?
[] 1 Yes
[] 2 No
[] 2 No
E. A car?
[] 1 Yes
[] 2 No
[] 2 No
F. A boat with a motor?
[] 1 Yes
[] 2 No
[] 2 No
G. A van?
[] 1 Yes
[] 2 No
[] 2 No
HC11. Does any member of your household have a computer or a tablet?
[] 1 Yes
[] 2 No
[] 2 No
HC12. Does any member of your household have a mobile telephone?
[] 1 Yes
[] 2 No
[] 2 No
HC13. Does your household have access to internet at home?
[] 1 Yes
[] 2 No
[] 2 No
HC14. Do you or someone living in this household own this dwelling or rent this dwelling from someone who does not live in it?
If "No", record "6" and specify.
[] 1 Own
[] 2 Rent
[] 6 Other (specify) _____
[] 2 Rent
[] 6 Other (specify) _____
HC15. Does any member of this household own any land that can be used for agriculture?
[] 1 Yes
[] 2 No (Go to HC17)
[] 2 No (Go to HC17)
HC16. How many ares of agricultural land do members of this household own?
If less than 1, record "000". If 995 or more, record "955"
_ _ Ares
[] 995 995 or more
[] 998 DK
[] 995 995 or more
[] 998 DK
HC17. Does this household own any farm animals or poultry?
[] 1 Yes
[] 2 No (Go to HC19)
[] 2 No (Go to HC19)
[page 8]
HC18. 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. Cows or bulls?
Number: _ _
C. Horses?
Number: _ _
D. Goats?
Number: _ _
E. Sheep?
Number: _ _
F. Chickens?
Number: _ _
G. Pigs?
Number: _ _
H. Rabbits?
Number: _ _
HC19. Does any member of this household have a bank account?
[] 1 Yes
[] 2 No
[] 2 No
[page 10]
Household Energy Use: EU
EU1. In your household, what type of cookstove is mainly used for cooking?
[] 01 Electric stove (Go to EU5)
[] 03 Liquefied petroleum gas (LPG)/cooking gas stove (Go to EU5)
[] 04 Piped natural gas stove (Go to EU5)
[] 08 Traditional solid fuel stove
[] 96 Other (specify)____ (Go to EU4)
[] 97 No food cooked in household (Go to EU6)
[] 03 Liquefied petroleum gas (LPG)/cooking gas stove (Go to EU5)
[] 04 Piped natural gas stove (Go to EU5)
[] 08 Traditional solid fuel stove
[] 96 Other (specify)____ (Go to EU4)
[] 97 No food cooked in household (Go to EU6)
EU2. Does it have a chimney?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
EU4. What type of fuel or energy source is used in this cookstove?
If more than one, record the main energy source for this cookstove.
[] 04 Coal
[] 06 Wood
[] 12 Fuel briquettes
[] 96 Other (specify) ____
[] 06 Wood
[] 12 Fuel briquettes
[] 96 Other (specify) ____
EU5. Is the cooking usually done in the house, in a separate building, or outdoors?
If in main house, probe: This is done in a separate room or not? If outdoors, probe: This is done on veranda, covered porch, or open air..
In main house
[] 01 No separate room
[] 02 In a separate room
[] 03 In a separate building
[] 02 In a separate room
[] 03 In a separate building
Outdoors
[] 04 Open air
[] 05 On veranda or covered porch
[] 05 On veranda or covered porch
[] 06 Other (specify) ____
[page 11]
EU6. What does your household mainly use for space heating when needed?
[] 01 Central heating (Go to EU8)
[] 02 Manufactured space heater, fireplace
[] 05 Traditional cookstove (solid fuel)
[] 07 Individual boiler
[] 96 Other (specify) (Go to EU8)
[] 97 No space heating in household (Go to EU9)
[] 02 Manufactured space heater, fireplace
[] 05 Traditional cookstove (solid fuel)
[] 07 Individual boiler
[] 96 Other (specify) (Go to EU8)
[] 97 No space heating in household (Go to EU9)
EU7. Does (type of heating from EU6) have a chimney?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
EU8. What type of fuel and energy source is used in this heater?
If more than one, record the main energy source for this heater.
[] 02 Electricity
[] 03 Piped natural gas
[] 04 Liquefied Petroleum Gas (in cylinders)
[] 09 Coal
[] 11 Wood and wood waste
[] 17 Fuel briquettes
[] 96 Other (specify) ____
[] 98 DK
[] 03 Piped natural gas
[] 04 Liquefied Petroleum Gas (in cylinders)
[] 09 Coal
[] 11 Wood and wood waste
[] 17 Fuel briquettes
[] 96 Other (specify) ____
[] 98 DK
[page 12]
EU9. At night, what does your household mainly use to light the household?
[] 1 Electricity
[] 3 Rechargeable flashlight, torch or lantern
[] 4 Battery powered flashlight, torch or lantern
[] 96 Other (specify) ____
[] 97 No lighting in household
[] 3 Rechargeable flashlight, torch or lantern
[] 4 Battery powered flashlight, torch or lantern
[] 96 Other (specify) ____
[] 97 No lighting in household
[page 13]
Water and sanitation: WS
WS1. What is the main source of drinking water used by members of your household?
Piped water
[] 11 Piped into dwelling (Go to WS7)
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour (Go to WS3)
[] 14 Public tap/standpipe (Go to WS3)
[] 21 Tube well/borehole (Go to WS3)
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour (Go to WS3)
[] 14 Public tap/standpipe (Go to WS3)
[] 21 Tube well/borehole (Go to WS3)
Dug well
[] 31 Protected well (Go to WS3)
[] 32 Unprotected well (Go to WS3)
[] 32 Unprotected well (Go to WS3)
[] 91 Bottled water
[] 96 Other (specify) ____ (Go to WS3)
[] 96 Other (specify) ____ (Go to WS3)
WS2. What is the main source of water used by members of your household for other purposes such as cooking and handwashing?
Piped water
[] 11 Piped into dwelling (Go to WS7)
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour
[] 14 Public tap/standpipe
[] 21 Tube well/borehole
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour
[] 14 Public tap/standpipe
[] 21 Tube well/borehole
Dug well
[] 31 Protected well
[] 32 Unprotected well
[] 32 Unprotected well
[] 96 Other (specify) ____
[page 16]
WS3. Where is that water source located?
[] 1 In own dwelling (Go to WS7)
[] 2 In own yard/plot (Go to WS7)
[] 3 Elsewhere
[] 2 In own yard/plot (Go to WS7)
[] 3 Elsewhere
WS4. How long does it take for members of your household to go there, get water, and come back?
[] 000 Members do not collect (go to WS7)
_ _ _Number of minutes
[] 998 DK
_ _ _Number of minutes
[] 998 DK
WS5. Who usually goes to this source to collect the water for your household?
Record the name of the person and copy the line number of this person from the list of household members module.
Name: ____
Line number: _ _
Line number: _ _
WS6. Since last (day of the week), how many times has this person collected water?
Number of times: _ _
[] 98 DK
[] 98 DK
WS7. In the last month, has there been any time when your household did not have sufficient quantities of drinking water?
[] 1 Yes, at least once
[] 2 No, always sufficient (Go to WS9)
[] 8 DK (Go to WS9)
[] 2 No, always sufficient (Go to WS9)
[] 8 DK (Go to WS9)
WS9. Do you or any other member of this household do anything to the water to make it safer to drink?
[] 1 Yes
[] 2 No (Go to WS11)
[] 8 DK (Go to WS11)
[] 2 No (Go to WS11)
[] 8 DK (Go to WS11)
[page 17]
WS10. What do you usually do to make the water safer to drink?
Probe: Anything else?
Continuing asking to find out what measures have been taken and record all the codes for mentioned measures.
[] A Boil
[] B Add chlorine
[] C Strain it through a cloth
[] D Use water filter (ceramic, sand, composite, ect)
[] F Let it stand
[] X Other (specify) ____
[] Z DK
[] B Add chlorine
[] C Strain it through a cloth
[] D Use water filter (ceramic, sand, composite, ect)
[] F Let it stand
[] X Other (specify) ____
[] Z DK
WS11. What kind of toilet facility do members of your household usually use?
If "Flush" or "Pour flush", probe: Where does it flush to?
Flush/pour flush
[] 11 Flush to piped sewer system (go to WS14)
[] 12 Flush to septic tank
[] 13 Flush to pit latrine
[] 15 Flush to somewhere else (go to WS14)
[] 18 Flush to DK where (go to WS14)
[] 12 Flush to septic tank
[] 13 Flush to pit latrine
[] 15 Flush to somewhere else (go to WS14)
[] 18 Flush to DK where (go to WS14)
Pit latrine
[] 21 Ventilated improved pit latrine
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 96 Other (specify) ____ (Go to WS14)
WS12. Has your (answer from WS11) ever been emptied?
[] 1 Yes
[] 4 No (Go to WS14)
[] 8 DK (Go to WS14)
[] 4 No (Go to WS14)
[] 8 DK (Go to WS14)
WS13. The last time (answer from WS11), where were the contents emptied to?
Probe: Was it removed by a service provider?
Removed by service provider
[] 1 To a treatment plant
[] 2 Buried in a covered pit
[] 3 To don't know where
[] 2 Buried in a covered pit
[] 3 To don't know where
Emptied by household
[] 4 Buried in a covered pit
[] 5 To uncovered pit or open ground
[] 6 Other (specify) ____
[] 8 DK
[] 5 To uncovered pit or open ground
[] 6 Other (specify) ____
[] 8 DK
[page 18]
WS14. Where is this toilet facility located?
[] 1 In own dwelling
[] 2 In own yard/plot
[] 3 Elsewhere
[] 2 In own yard/plot
[] 3 Elsewhere
WS15. Do you share this facility with other households?
[] 1 Yes
[] 2 No (Go to SA3)
[] 2 No (Go to SA3)
WS16. Do you share this facility only with members of other households that you know (not public), or is the facility open to the use of the general public?
[] 1 Shared with known households (not public)
[] 2 Shared with general public (Go to next module)
[] 2 Shared with general public (Go to next module)
WS17. How many households in total use this toilet facility, including your own household?
0 _ Number of households (if less than 10)
[] 10 Ten or more households
[] 98 DK
[] 10 Ten or more households
[] 98 DK
[page 19]
Iodine Deficiency Prevention: IDP
SA3. Do you know about the benefits of iodized salt as the main available means for prevention of iodine deficiency diseases?
[] 1 Yes
[] 2 No
[] 2 No
SA4. Do you use iodised salt for cooking?
If the answer is "Yes", ask: How often do you use iodised salt for cooking: constantly or sometimes?
[] 1 Yes, constantly
[] 2 Yes, sometimes
[] 3 No
[] 6 Other (specify)
[] 2 Yes, sometimes
[] 3 No
[] 6 Other (specify)
HH13. Record the time.
Hours and minutes: _ _:_ _
HH18. Check HL6 in the "List of household members" and indicate the total number of children age 5-17 years:
[] 0 No children (Go to HH29)
[] 1 1 child (Go to HH27)
2 or more children (number): _
[] 1 1 child (Go to HH27)
2 or more children (number): _
[page 21]
HH19. List each of the children age 5-17 years below in the order they appear in the list of household members. Record the line number, name, sex, and age for each child.
HH20. Rank number: _
HH21. Line number from HL1: _ _
HH22. Name from HL2: ____
HH23. Sex from HL4
[] 1 Male
[] 2 Female
[] 2 Female
HH24. Age from HL6: _ _
HH25. Check the last digit of the household number (HH2) from the household information panel. This is the number of the row you should go to in the table below.
Check the total number of children in HH18 above. This is the number of the column you should go to in the table below.
Find the box where the row and the column meet and record the number that appears in the box. This is the rank number (HH20) of the selected child for questionnaire for children age 5-17.
Last digit of household number (from HH2): _
Total number of eligible children in the household (from HH18): _
Total number of eligible children in the household (from HH18): _
HH26. Record the rank number (HH20), line number (HH21), name (HH22) and age (HH24) of the selected child for questionnaire for children age 5-17.
Rank number: _
Line number: _ _
Name: ____
Age: _ _
Line number: _ _
Name: ____
Age: _ _
HH27. Record the rank number as "1"and record the line number (HL1), the name (HL2) and age (HL6) of this child from the list of household members.
Rank Number: _
Line Number: _ _
Name: ____
Age: _ _
Line Number: _ _
Name: ____
Age: _ _
HH28. Issue a questionnaire for children age 5-17 to be administered to the mother/caretaker of this child.
[page 22]
HH29. Check HL8 in the list of household members: Are there any women age 15-49?
[] 1 Yes
[] 2 No (Go to HH34)
[] 2 No (Go to HH34)
HH30. Issue a separate questionnaire for individual women for each woman age 15-49 years.
HH31. Check HL6 and HL8 in the list of household members: Are there any girls age 15-17?
[] 1 Yes
[] 2 No (Go to HH34)
[] 2 No (Go to HH34)
HH32. Check HL20 in the list of household members: Is consent required for interviewing at least one girl age 15-17?
[] 1 Yes
[] 2 No(Go to HH34)
[] 2 No(Go to HH34)
HH33. Get the consent from mother (caretaker) for a survey of girl(s) aged 15-17 years living in the household.
Consent for the survey:
[] Was obtained for all girls age 15-17 (Continue with HH34)
[] Was obtained for not all girls age 15-17 (Record "06" in WM17 on individual questionnaires for those adult consent was not given. Then continue with HH34.)
[] Not obtained for any girls age 15-17 (Record "06" in WM17 on individual questionnaires for whom adult consent was not given. Then continue with HH34.)
[] Was obtained for not all girls age 15-17 (Record "06" in WM17 on individual questionnaires for those adult consent was not given. Then continue with HH34.)
[] Not obtained for any girls age 15-17 (Record "06" in WM17 on individual questionnaires for whom adult consent was not given. Then continue with HH34.)
HH34. Check HH8 in the household information panel: Is the household selected for Questionnaire for Men?
[] 1 Yes, HH8=1
[] 2 No, HH8=2 (Go to HH40)
[] 2 No, HH8=2 (Go to HH40)
HH35. Check HL9 in the "List of household members": Are there any men age 15-49?
[] 1 Yes
[] 2 No (Go to HH40)
[] 2 No (Go to HH40)
HH36. Issue a separate questionnaire for individual men for each man age 15-49 years.
HH37. Check HL6 and HL8 in the list of household members: Are there any boys age 15-17?
[] 1 Yes
[] 2 No (Go to HH40)
[] 2 No (Go to HH40)
HH38. Check HL20 in the "List of household members": Is consent required for interviewing at least one boy age 15-17?
[] 1 Yes
[] 2 No(Go to HH40)
[] 2 No(Go to HH40)
HH39. Get the consent from mother (caretaker) for a survey of boy(s) aged 15-17 years living in the household.
Consent for the survey:
[] Was obtained for all boys age 15-17 (Continue with HH40)
[] Was obtained for not all boys age 15-17 (Record "06" in MWM17 on individual questionnaires for those adult consent was not given. Then continue with HH40.)
[] Not obtained for any boys age 15-17 (Record "06" in MWM17 on individual questionnaires for whom adult consent was not given. Then continue with HH340)
[] Was obtained for not all boys age 15-17 (Record "06" in MWM17 on individual questionnaires for those adult consent was not given. Then continue with HH40.)
[] Not obtained for any boys age 15-17 (Record "06" in MWM17 on individual questionnaires for whom adult consent was not given. Then continue with HH340)
[page 23]
HH40. Check HL10 in the "List of household members": Are there any children age 0-4?
[] 1 Yes
[] 2 No (Go to HH42)
[] 2 No (Go to HH42)
HH41. Issue a separate questionnaire for children under five for each child age 0-4 years.
HH45. Now return to the household information panel and,
Record "01" in question HH46. Record the name and the line number (from the list of household members) of the respondent to the household questionnaire interview in HH47. Fill the questions HH48 ? HH52. Thank the respondent for his/her cooperation and then proceed with the administration of the remaining individual questionnaire(s) in this household.
If there is no individual questionnaire to be completed in this household thank the respondent for his/her cooperation and complete the survey.
[page 24]
Interviewer's Observations ________
Supervisor's Observations ________