MICS Household Questionnaire
MICS5 Belize
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
_ _ / _ _ /2015
HH6. Area
[] 1 Urban
[] 2 Rural
[] 2 Rural
HH7. Region
[] 1 Corozal
[] 2 Orange Walk
[] 3 Belize (excluding Belize City South Side)
[] 4 Belize City South Side
[] 5 Cayo
[] 6 Stann creek
[] 7 Toledo
[] 2 Orange Walk
[] 3 Belize (excluding Belize City South Side)
[] 4 Belize City South Side
[] 5 Cayo
[] 6 Stann creek
[] 7 Toledo
We are from the statistical institute of Belize. We are conducting a survey about the situation of children, families and households. I would like to talk to you about these subjects. The interview will take about 25 minutes. All the information we obtain will remain strictly confidential. May I start now?
[] Yes, permission is given (Go to HH18 to record the time and then begin the interview.)
[] No, permission is not given (Circle 04 in HH9. Discuss this result with your supervisor.)
[] No, permission is not given (Circle 04 in HH9. Discuss this result with your supervisor.)
HH9. Result of household interview:
[] 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/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/address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
After the household questionnaire has been completed, fill in the following information:
HH10. Respondent to household questionnaire:
Name: ____
Line no: _ _
Line no: _ _
After the household questionnaire has been completed, fill in the following information:
HH11. Total number of household members: _ _
After the household questionnaire has been completed, fill in the following information:
HH12. Number of women age 15-49 years: _ _
After all questionnaires for the household have been completed, fill in the following information:
HH13. Number of women's questionnaires completed: _ _
After the household questionnaire has been completed, fill in the following information:
If the household is selected for Questionnaire for Men
HH13A. Number of Men age 15-49 years:_ _
After all questionnaires for the household have been completed, fill in the following information:
HH13B. Number of man's questionnaires completed: _ _
After the household questionnaire has been completed, fill in the following information:
HH14. Number of children under age 5: _ _
After all questionnaires for the household have been completed, fill in the following information:
HH15. Number of under-5 questionnaires completed: _ _
HH18 Record the time
_ _ Hour
_ _ Minutes
[] am
[] pm
_ _ Minutes
[] am
[] pm
List of Household Members: HL
First, please tell me the name of each person who usually lives here, that is, persons who sleep at least 4 nights of the week and share at least one daily meal. Please start 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? This may include children in school or adults at work.
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 list of household members have been used.
HL1. Line number: _ _
HL2. Name: ____
HL3. What is the relation-ship of (name) to the head of household?
Relation: _ _
Code for HL3 Relationship to head of household
[] 01 Head
[] 02 Spouse/partner
[] 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
[] 14 Household helper (live-in)
[] 96 Other (not related)
[] 98 DK
[] 02 Spouse/partner
[] 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
[] 14 Household helper (live-in)
[] 96 Other (not related)
[] 98 DK
HL4. Is the (name) Male or Female?
[] 1 Male
[] 2 Female
[] 2 Female
HL5. What is (name's) date of birth?
Month (98 DK): _ _
Year (9998 DK): _ _ _ _
Year (9998 DK): _ _ _ _
HL6. How old is (name)?
Record in completed years. If age is 95 or above '95':
Age: _ _
HL7. Circle line no. if woman age 15-49
HL7A. Circle line no. If man age 15-49
HL7B. Circle line no. If children age 0-4.
HL11. Is (name)'s natural mother alive?
[] 1 Yes
[] 2 No (Go to HL13)
[] 8 DK (Go to HL13)
[] 2 No (Go to HL13)
[] 8 DK (Go to HL13)
HL12. Does (name)'s natural mother live in this household? _ _
If "Yes", record line no. of mother and go to HL13. If "No", record 00.
HL12A. Where does (name)'s natural mother live?
[] 1 In another household in this country
[] 2 Institution in this country
[] 3 Abroad
[] 8 DK
[] 2 Institution in this country
[] 3 Abroad
[] 8 DK
HL13. Is (name)'s natural father alive
[] 1 Yes
[] 2 No (Go to HL15)
[] 8 DK (Go to HL15)
[] 2 No (Go to HL15)
[] 8 DK (Go to HL15)
HL14. Does (name)'s natural father live in this household? _ _
If "Yes", record line no. of father and go to HL15. If "No", record 00.
HL14A. Where does (name)'s natural father live?
[] 1 In another household in this country
[] 2 Institution in this country
[] 3 Abroad
[] 4 DK
[] 2 Institution in this country
[] 3 Abroad
[] 4 DK
HL15. Record line no. of mother from HL12 if indicated.
If HL12 is blank or '00' ask: who is the primary caretaker of (name)?
Number: _ _
[] Tick here if additional questionnaire used [After HL1 to HL4 questions]
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 line number and other identifying information in the information panel of a separate individual women's questionnaire.
For each man age 15-49 years, write his name and line number and other identifying information in the information panel of a separate individual man'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 a separate under-5 questionnaire.
You should now have a separate questionnaire for each eligible woman, each eligible man, and each child under five in the household.
Education: ED
ED1. Line number: _ _
ED2. Name and age
Copy from HL2 and HL6.
Name: ____
Age: _ _
Age: _ _
ED3. Has (name) ever attended school or pre-school?
For household members age 5 and above
[] 1. Yes
[] 2. No (Go to next line)
[] 2. No (Go to next line)
ED4A. What is the highest level school (name) has ever attended?
For household members age 5 and above. If level=00, skip to ED5
[] 00 Preschool
[] 01 Infant
[] 02 Primary
[] 03 Secondary
[] 04 Associates
[] 05 Bsc. And higher
[] 96 Other
[] 98 DK
[] 01 Infant
[] 02 Primary
[] 03 Secondary
[] 04 Associates
[] 05 Bsc. And higher
[] 96 Other
[] 98 DK
ED4B. What is the highest standard/form/year (name) completed at this level?
For household members age 5 and above. If the first std/form/year at this level is not completed, enter "00".
Std/form/year: _ _
ED5. During the current school year, did (name) attend school or preschool at any time?
For household members age 5-24 years
[] 1. Yes
[] 2. No (Go to ED7)
[] 2. No (Go to ED7)
ED6. During this school year, which level and standard/form.year was (name) attending?
For household members age 5-24 years. If level=00 skip to ED7
Level:
[] 00 Preschool
[] 01 Infant
[] 02 Primary
[] 03 Secondary
[] 04 Associates
[] 05 Bsc. And higher
[] 96 Other
[] 98 DK
[] 01 Infant
[] 02 Primary
[] 03 Secondary
[] 04 Associates
[] 05 Bsc. And higher
[] 96 Other
[] 98 DK
Standard/form/year:
_ _
[] 98 DK
[] 98 DK
ED7. During the previous school year, did (name) attend school or preschool at any time?
For household members age 5-24 years
[] 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)
ED8. During that school year, which level and standard/form/year did (name) attend?
For household members age 5-24 years
If level=0 skip to ED7
Level:
[] 00 Preschool
[] 01 Infant
[] 02 Primary
[] 03 Secondary
[] 04 Associates
[] 05 Bsc. And higher
[] 96 Other
[] 98 DK
[] 01 Infant
[] 02 Primary
[] 03 Secondary
[] 04 Associates
[] 05 Bsc. And higher
[] 96 Other
[] 98 DK
Standard/form/year:
_ _
[] 98 DK
[] 98 DK
Selection of One Child For Child Discipline: SL
SL1. Check HL6 in the list of household members and write the total number of children age 1-14 years.
Total number: _ _
SL2. Check the number of children age 1-14 years in SL1:
[] Zero (Go to household characteristics module.)
[] One (Go to SL9 and record the rank number as "1", enter the line number, child's name and age.)
[] Two or more (Continue with SL2A.)
[] One (Go to SL9 and record the rank number as "1", enter the line number, child's name and age.)
[] Two or more (Continue with SL2A.)
SL2A. List each of the children age 1-14 years below in the order they appear in the List of household members. Do not include other household members outside of the age range 1-14 years. Record the line number, name, sex, and age for each child.
SL3. Rank number: _
SL4. Line number from HL1: _ _
SL5. Name from HL2: ____
SL6. Sex from HL4
[] 1 Male
[] 2 Female
[] 2 Female
SL7. Age from HL6: _ _
SL8. Check the last digit of the household number (HH2) from the cover page. This is the number of the row you should go to in the table below.
Check the total number of children age 1-14 years in SL1 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 circle the number that appears in the box. This is the rank number (SL3) of the selected child.
Last Digit of Household Number (from HH2): _
Total Number of Eligible Children in the Household (from SL1): [2 to 8+] _
Total Number of Eligible Children in the Household (from SL1): [2 to 8+] _
SL9. Record the rank number (SL3), line number (SL4), name (SL5) and age (SL7) of the selected child.
Rank number: _
Line number: _ _
Name: ____
Age: _ _
Line number: _ _
Name: ____
Age: _ _
Child Discipline: CD
CD2. Write the line number and name of the child from SL9.
Line number: _ _
Name: ____
Name: ____
CD3. Adults use certain ways to teach children the right behaviour or to address a behaviour problem. I will read various methods that are used. Please tell me if you or anyone else in your household has used this method with (name) in the past month.
[A] Took away privileges, forbade something (name) liked or did not allow him/her to leave the house.
[] 1 Yes
[] 2 No
[] 2 No
[B] Explained why (name)'s behaviour was wrong.
[] 1 Yes
[] 2 No
[] 2 No
[C] Shook him/her.
[] 1 Yes
[] 2 No
[] 2 No
[D] Shouted, yelled at or screamed at him/her.
[] 1 Yes
[] 2 No
[] 2 No
[E] Gave him/her something else to do.
[] 1. Yes
[] 2. No
[] 2. No
[F] Spanked, hit or slapped him/her on the bottom with bare hand.
[] 1 Yes
[] 2 No
[] 2 No
[G] 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
[] 2 No
[H] Called him/her dumb, lazy, or another name like that.
[] 1 Yes
[] 2 No
[] 2 No
[I] Hit or slapped him/her on the face, head or ears.
[] 1 Yes
[] 2 No
[] 2 No
[J] Hit or slapped him/her on the hand, arm, or leg.
[] 1 Yes
[] 2 No
[] 2 No
[K] Beat him/her up, that is hit him/her over and over as hard as one could.
[] 1 Yes
[] 2 No
[] 2 No
CD4. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?
[] 1 Yes
[] 2 No
[] 8 DK/no opinion
[] 2 No
[] 8 DK/no opinion
Household Characteristics: HC
HC1A. What is the religion of the head of this household?
[] 01 Anglican
[] 02 Baptist
[] 03 Jehovah?s Witness
[] 04 Mennonite
[] 05 Methodist
[] 06 Nazarene
[] 07 Pentecostal
[] 08 Roman Catholic
[] 09 Seventh-Day Adventist
[] 97 None
[] 96 Other (specify) ____
[] 98 Don?t know
[] 02 Baptist
[] 03 Jehovah?s Witness
[] 04 Mennonite
[] 05 Methodist
[] 06 Nazarene
[] 07 Pentecostal
[] 08 Roman Catholic
[] 09 Seventh-Day Adventist
[] 97 None
[] 96 Other (specify) ____
[] 98 Don?t know
HC1B. What is the mother tongue/native language of the head of this household?
[] 01 Chinese/Taiwanese
[] 02 Creole
[] 03 English
[] 04 German
[] 05 Hindi
[] 06 Maya
[] 07 Spanish
[] 08 Garifuna
[] 96 Other (specify) ____
[] 02 Creole
[] 03 English
[] 04 German
[] 05 Hindi
[] 06 Maya
[] 07 Spanish
[] 08 Garifuna
[] 96 Other (specify) ____
HC1C. To what ethnic group does the head of this household belong?
[] 01 Asian
[] 02 Caucasian
[] 03 Creole
[] 04 East Indian
[] 05 Maya
[] 06 Mennonite
[] 07 Mestizo/Spanish/Latino
[] 08 Garifuna
[] 96 Other (specify) ____
[] 02 Caucasian
[] 03 Creole
[] 04 East Indian
[] 05 Maya
[] 06 Mennonite
[] 07 Mestizo/Spanish/Latino
[] 08 Garifuna
[] 96 Other (specify) ____
HC2. How many rooms in this household are used for sleeping?
Number of rooms: _ _
HC3. Main material of the dwelling floor.
Record observation.
Natural floor
[] 11 Earth/sand
Rudimentary floor
[] 21 Wood planks
[] 23 Plywood
[] 23 Plywood
Finished floor
[] 31 Parquet or polished wood
[] 32 Vinyl or asphalt strips/marley
[] 33 Ceramic tiles/cement tiles
[] 34 Cement/concrete
[] 35 Carpet
[] 32 Vinyl or asphalt strips/marley
[] 33 Ceramic tiles/cement tiles
[] 34 Cement/concrete
[] 35 Carpet
[] 96. Other (specify) ____
HC4. Main material of the roof.
Record observation.
Natural roofing
[] 12 Thatch/palm leaf/bayleaf
Rudimentary roofing
[] 24 Cardboard
[] 25 Rubber rye
[] 25 Rubber rye
Finished roofing
[] 31 Metal/tin/corrugated zinc
[] 34 Ceramic/roofing tiles
[] 35 Cement/concrete
[] 36 Roofing shingles
[] 96 Other (specify) ____
[] 34 Ceramic/roofing tiles
[] 35 Cement/concrete
[] 36 Roofing shingles
[] 96 Other (specify) ____
HC5. Main material of the exterior walls.
Record observation
Natural walls
[] 11 No walls
[] 14 Palmetto/wildcane/sticks
[] 14 Palmetto/wildcane/sticks
Rudimentary walls
[] 21 Bamboo/palmetto with mud/white lime
[] 22 Stone with mud
[] 24 Plywood
[] 25 Carton/Cardboard
[] 26 Reused wood
[] 22 Stone with mud
[] 24 Plywood
[] 25 Carton/Cardboard
[] 26 Reused wood
Finished Walls
[] 31 Cement
[] 32 Stone with lime/concrete
[] 33 Bricks
[] 34 Cement bricks
[] 36 Wood planks/shingles
[] 37 Wood and concrete
[] 38 Stucco
[] 39 Plycem
[] 40 Metal/tin/corrugated/zinc
[] 32 Stone with lime/concrete
[] 33 Bricks
[] 34 Cement bricks
[] 36 Wood planks/shingles
[] 37 Wood and concrete
[] 38 Stucco
[] 39 Plycem
[] 40 Metal/tin/corrugated/zinc
[] 96 Other (specify) ____
HC6. What type of fuel does your household mainly use for cooking?
[] 01 Electricity (Go to HC8)
[] 02 Butane/Liquefied petroleum gas (LPG) (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene (Go to HC8)
[] 07 Charcoal
[] 08 Wood
[] 11 Agricultural crop residue
[] 95 No food cooked in household (Go to HC8)
[] 96 Other (specify) ____
[] 02 Butane/Liquefied petroleum gas (LPG) (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene (Go to HC8)
[] 07 Charcoal
[] 08 Wood
[] 11 Agricultural crop residue
[] 95 No food cooked in household (Go to HC8)
[] 96 Other (specify) ____
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?
In the house
[] 1 In a separate room used as a kitchen
[] 2 Elsewhere in the house
[] 2 Elsewhere in the house
[] 3 In a separate building
[] 4 Outdoors
[] 6 Other (specify) ____
[] 4 Outdoors
[] 6 Other (specify) ____
HC8. Does your household have:
[A] Electricity?
[] 1 Yes
[] 2 No
[] 2 No
[B] A radio?
[] 1 Yes
[] 2 No
[] 2 No
[C] A television?
[] 1 Yes
[] 2 No
[] 2 No
[D] A fixed line telephone?
[] 1 Yes
[] 2 No
[] 2 No
[E] A refridgerator?
[] 1 Yes
[] 2 No
[] 2 No
[F] A fan?
[] 1 Yes
[] 2 No
[] 2 No
[G] A micro wave oven?
[] 1 Yes
[] 2 No
[] 2 No
[H] A security alarm system?
[] 1 Yes
[] 2 No
[] 2 No
[I] A washing machine?
[] 1 Yes
[] 2 No
[] 2 No
[J] A DVD player?
[] 1 Yes
[] 2 No
[] 2 No
[K] A gas bar-b-q grill?
[] 1 Yes
[] 2 No
[] 2 No
[L] An air conditioner?
[] 1 Yes
[] 2 No
[] 2 No
[M] A water cooler?
[] 1 Yes
[] 2 No
[] 2 No
[N] A sofa set?
[] 1 Yes
[] 2 No
[] 2 No
[O] A dining room set?
[] 1 Yes
[] 2 No
[] 2 No
[P] A clothes closet?
[] 1 Yes
[] 2 No
[] 2 No
HC9. Does any member of your household own:
[A] A watch?
[] 1 Yes
[] 2 No
[] 2 No
[B] A cellphone?
[] 1 Yes
[] 2 No
[] 2 No
[C] A bicycle?
[] 1 Yes
[] 2 No
[] 2 No
[D] A motorcycle or scooter?
[] 1 Yes
[] 2 No
[] 2 No
[E] An animal-drawn cart?
[] 1 Yes
[] 2 No
[] 2 No
[F] A car or truck?
[] 1 Yes
[] 2 No
[] 2 No
[G] A boat with a motor?
[] 1. Yes
[] 2. No
[] 2. No
[H] A tablet computer?
[] 1. Yes
[] 2. No
[] 2. No
[I] A fishing rod?
[] 1. Yes
[] 2. No
[] 2. No
[J] A weight training machine?
[] 1. Yes
[] 2. No
[] 2. No
[K] A computer?
[] 1. Yes
[] 2. No
[] 2. No
[L] Canoe/a boat without a motor?
[] 1. Yes
[] 2. No
[] 2. No
HC10. Do you or someone living in this household own this dwelling?
If "No", then ask: Do you rent this dwelling from someone not living in this household?
If "Rented from someone else", circle "2". For other responses, circle "6".
[] 1 Own
[] 2 Rent
[] 6 Other (specify) ____
[] 2 Rent
[] 6 Other (specify) ____
HC11. Does any member of this household own any land that can be used for agriculture?
[] 1 Yes
[] 2 No (Go to HC13)
[] 2 No (Go to HC13)
HC12. How many acres of agricultural land do members of this household own?
If less than one, record "00". If 95 or more, record '95'. If unknown, record '98'.
Acres: _ _
HC13. Does this household own any livestock, herds, other farm animals, or poultry?
[] 1 Yes
[] 2 No (Go to HC15)
[] 2 No (Go to HC15)
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, milk cows, or bulls?
Numbers: _ _
[B] Horses, donkeys, or mules?
Numbers: _ _
[C] Goats?
Numbers: _ _
[D] Sheep?
Numbers: _ _
[E] Chickens?
Numbers: _ _
[F] Pigs?
Numbers: _ _
[G] Turkey, ducks?
Numbers: _ _
HC15. Does any member of this household have a bank account, a bank book or credit union book?
[] 1. Yes
[] 2. No
[] 2. No
Water and Sanitation: WS
WS1. What is the main source of drinking water for members of your household?
Piped water
[] 11 Piped into dwelling (Go to WS6)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped to neighbour (Go to WS6)
[] 14 Public pipe/standpipe (Go to WS3)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped to neighbour (Go to WS6)
[] 14 Public pipe/standpipe (Go to WS3)
[] 21. Tube well, borehole, hand pump (Go to WS3)
Dug Well
[] 31 Protected well (Go to WS3)
[] 32 Unprotected 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)
[] 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)
[] 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 washing, bathing and handwashing?
Piped water
[] 11 Piped into dwelling (Go to WS6)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped to neighbour (Go to WS6)
[] 14 Public pipe/standpipe
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped to neighbour (Go to WS6)
[] 14 Public pipe/standpipe
[] 21 Tube well, borehole, hand pump
Dug Well
[] 31 Protected well
[] 32 Unprotected well
[] 32 Unprotected well
Water from spring
[] 41 Protected spring
[] 42 Unprotected 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) ____
[] 61 Tanker-truck
[] 71 Cart with small tank/drum
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96 Other (specify) ____
WS3. Where is that water source located?
[] 1 In own dwelling (Go to WS6)
[] 2 In own yard/plot (Go to WS6)
[] 3 Elsewhere
[] 2 In own yard/plot (Go to WS6)
[] 3 Elsewhere
WS4. How long does it take to go there, get water, and come back?
Number of minutes: _ _ _
[] 998 DK
[] 998 DK
WS5. Who usually goes to this source to collect the water for your household?
Probe: is this person under age 15? What sex?
[] 1 Adult woman (age 15+ years)
[] 2 Adult man (age 15+ years)
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK
[] 2 Adult man (age 15+ years)
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK
WS6. Do you do anything to the water to make it safer to drink?
[] 1 Yes
[] 2 No (Go to WS8)
[] 8 DK (Go to WS8)
[] 2 No (Go to WS8)
[] 8 DK (Go to WS8)
WS7. What do you usually do to make the water safer to drink?
Probe: 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
[] 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
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 not possible to determine, ask permission to observe the facility.
Flush/pour flush
[] 11 Flush to piped sewer system
[] 12 Flush to septic tank
[] 13 Flush to pit (latrine)
[] 14 Flush to somewhere else
[] 15 Flush to unknown place/not sure/DK where
[] 12 Flush to septic tank
[] 13 Flush to pit (latrine)
[] 14 Flush to somewhere else
[] 15 Flush to unknown place/not sure/DK where
Pit latrine
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 31 Composting toilet
[] 41 Bucket
[] 51 Hanging toilet, hanging latrine
[] 95 No facility, bush, field (Go to next module)
[] 96 Other (specify) ____
[] 41 Bucket
[] 51 Hanging toilet, hanging latrine
[] 95 No facility, bush, field (Go to next module)
[] 96 Other (specify) ____
WS9. Do you share this facility with others who are not members of your household?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
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?
[] 1 Other households only (not public)
[] 2 Public facility (Go to next module)
[] 2 Public facility (Go to next module)
WS11. How many households in total use this toilet facility, including your own household?
Number of households (if less than 10): 0_
[] 10 Ten or more households
[] 98 DK
[] 10 Ten or more households
[] 98 DK
Handwashing: HW
HW1. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?
[] 1 Observed
Not Observed
Not Observed
[] 2 Not in dwelling/plot/yard (Go to HW4)
[] 3 No permission to see (Go to HW4)
[] 6 Other reason (specify) ____ (Go to HW4)
[] 3 No permission to see (Go to HW4)
[] 6 Other reason (specify) ____ (Go to HW4)
HW2 Observe presence of water at the place for handwashing. Verify by checking the tap/pump, or basin, bucket, water container or similar objects for presence of water
[] 1 Water is available
[] 2 Water is not available
[] 2 Water is not available
HW3A. Is soap, detergent or ash/sand present at the place for handwashing?
[] 1 Yes, present
[] 2 No, not present (Go to HW4)
[] 2 No, not present (Go to HW4)
HW3B Record you observation
Circle all that apply
[] A Bar soap (Go to HH19)
[] B Detergent (powder/liquid/paste) (Go to HH19)
[] C Liquid soap (Go to HH19)
[] D Ash/sand (Go to HH19)
[] B Detergent (powder/liquid/paste) (Go to HH19)
[] C Liquid soap (Go to HH19)
[] D Ash/sand (Go to HH19)
HW4 Do you have any bar soap, soap powder, liquid soap or sand in your house for washing hands?
[] 1 Yes
[] 2 No (Go to HH19)
[] 2 No (Go to HH19)
HW5A. Can you please show it to me?
[] 1 Yes, shown
[] 2 No, not shown (Go to HH19)
[] 2 No, not shown (Go to HH19)
HW5B Record your observation
Circle all that apply
[] A Bar soap
[] B Detergent (powder/liquid/paste)
[] C Liquid soap
[] D Ash/sand
[] B Detergent (powder/liquid/paste)
[] C Liquid soap
[] D Ash/sand
HH19. Record the time
Hours and minutes: _ _:_ _
[] AM
[] PM
[] AM
[] PM
Salt Iodization: SI
SI1. We would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?
Once you have tested the salt, circle number that corresponds to test outcome.
[] 1 Not iodized - 0 PPM
[] 2 More than 0 PPM and less than 15 PPM
[] 3 15 PPM or more
[] 4 No salt in the house
[] 5 Salt not tested (specify reason) ____
[] 2 More than 0 PPM and less than 15 PPM
[] 3 15 PPM or more
[] 4 No salt in the house
[] 5 Salt not tested (specify reason) ____
HH20. Thank the respondent for his/her cooperation and check the list of household members:
[] A separate questionnaire for individual women has been issued for each woman age 15-49 years in the list of household members (HL7).
[] A separate questionnaire for individual men has been issued for each man age 15-49 years in the list of household members (HL7A).
[] A separate questionnaire for children under five has been issued for each child under age 5 years in the list of household members (HL7B).
Return to the cover page and make sure that the result of the household interview (HH9), the name and line number of the respondent to the household questionnaire (HH10), and the number of eligible women (HH12), men (HH13A), and under-5s (HH14) are entered. Make arrangements for the administration of the remaining questionnaire(s) in this household.