We are from (country-specific affiliation). 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 (number) 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

HH1. Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

HH5. Day/month/year of interview _ _ / _ _ / _ _ _ _

HH6. Area:

HH7. Prefecture:

HH8. Name of head of household: ____

After all questionnaires for the household have been completed, fill in the following information:
[Note: HH9 to HH16]

HH8A. Household selected for men's questionnaire and tests for anemia and HIV?

HH9. Result of HH interview:

HH10. Respondent to HH questionnaire

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: _ _

HH15A. No. of men age 15-59 eligible for interview: _ _ _ _

HH15B. No of men questionnaires completed: _ _

Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as call-back times, incomplete individual interview forms, number of attempts to re-visit, etc.

HH16. Data entry clerk: _ _

Household listing form: HL

First, please tell me the name of each person who usually lives here, starting with the head of the household.
List the head of the household in line 01. List all household members (HL2), their relationship to the household head (HL3), and their sex (HL4).
Then ask: are there any others who live here, even if they are not at home now? (These may include children in school or at work). If yes, complete listing.
Then, ask questions starting with hl5 for each person at a time. Add a continuation sheet if there are more than 15 household members.
[] Tick here if continuation sheet used

HL1. Line no.: _ _

HL2. Name: ____

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

HL4. Is (name) male or female?

HL5. How old is (name)? How old was (name) in his/her last birthday?
Record in Completed years
HL6. Eligible for women's interview and Anemia/HIV test

HL6A. Eligible for men's interview Anemia/HIV test

HL6B. Eligible for children under five anemia test

HL7. Eligible for child labour module
For each child age 5-14: Who is the mother or primary caretaker of this child?

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

If 18-59 years old:
HL8A. Was (name) very sick for at least 3 months of the past 12 months?

For children age 0-17 years ask HL9-HL12

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

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

HL10A. If the mother doesn't live in the household: Was (name)'s mother very sick for at least 3 months of the past 12 months?

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

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

HL12A. If the father doesn't live in the household: Was (name)'s father very sick for at least 3 months of the past 12 months?

Are there any other persons living here - even if they are not members of your family or do not have parents living in this household?
Including children at work or at school? If yes, insert child's name and complete form.
Then, complete the totals below.

Totals

Now for each woman age 15-49 years, write her name and line number and other identifying information in the information panel of the women's questionnaire.
For each child under age 5, write his/her name and line number and the line number of his/her mother or caretaker in the information panel of the questionnaire for children under five.
You should now have a separate questionnaire for each eligible woman and each child under five in the household.

Education Module: ED

For household members age 5 and above

ED1. Line no. _ _

ED1A. Name ____

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

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

For household members age 5-24 years

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

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

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

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

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

Water and sanitation module: WS

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

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

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

WS4. Who usually goes to this source to fetch the water for your household?
Probe: Is this person under age 15? What sex?
Circle code that best describes this person.

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

WS6. What do you usually do to the water to make it safer to drink?
Anything else?
Record all items mentioned.
WS7. What kind of toilet facility do members of your household usually use?
If "flush" or "pour flush", probe: Where does it flush to?
If necessary, ask permission to observe the facility.

WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

Household characteristics module: HC

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

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

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

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

HC3. Main material of the dwelling floor:
Record observation.
HC4. Main material of the roof.
Record observation.
HC5. Main material of the walls.
Record observation.
HC6. What type of fuel does your household mainly use for cooking?

HC7. In this household, is food cooked on an open fire, an open stove or a closed stove?
Probe for type.
HC7A. Does the fire/stove have a chimney or a hood?

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

HC9. Does your household have:





HC9. Does your household have:

HC10. Does any member of your household own:







ST1. Do you feel secure from eviction from this dwelling?

Child labour module: CL

To be administered to mother/caretaker of each child in the household age 5 through 14 years. For household members below age 5 or above age 14, leave rows blank.
Now I would like to ask about any work children in this household may do.

CL1. Line no. _ _

CL2. Name: ____

CL3. During the past week did (name) any kind of work for someone who is not a member of this household?
If yes: For pay in cash or kind?

CL4. If yes: Since last (day of the week), about how many hours did he/she do this work for someone who is not a member of this household?

CL5. At any time during the past year, did (name) do any kind of work for someone who is not a member of this household?
If yes: For pay in cash or kind?

CL6. During the past week, did (name) help with household chores such as shopping, collecting firewood, cleaning, fetching water, or caring for children?

CL7. If yes: Since last (day of the week), about how many hours did he/she spend doing these chores? _ _

CL8. During the past week, did (name) do any other family work (on the farm or in a business or selling goods in the street)

CL9. If yes: Since last (day of the week), about how many hours did he/she do this work? _ _

Orphan-hood Module

OV1. Verify HL5: Are there any children aged 0-17?
OV2. Has any usual member of your household died in the past 12 months?

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

OV4. Of those who died in this period, was anyone between 18 and 59 years old
seriously ill in 3 of the last 12 months before he/she died?

OV4A. Verify HL5 and OV4.

OV5. Return to the Household listing and check the following:

OV8A. List below all children aged 0?17 years. Register the names, line numbers and ages of all the children, starting with the first child and continuing in the order in which they appear in the household listing module. use a continuation questionnaire of there are more than four children aged 0?17 years in the household. After listing all the children, continue with OV9. ask all the questions for one child before passing to the next child..
OV8B. List all children aged 0-17 below. Record game, line numbers and ages of all children, beginning with the first child and continue in order in which listed in the household listing module. Use a continuation sheet if there are more than 4 children age 0-17 in the household. Ask all questions for one child before moving to the next child.
1st child
Name (from HL2) ____
Line number (from HL1) __
Age (from HL5) __ __
2nd child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ __
3rd child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ __
4th child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ _____ _

[Questions OV9 to OV218 are for all the children listed in OV8]
OV9. I would like to ask you about any formal, organized help or support that your HH may have received for (Name) and for which you did not have to pay. By formal organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community-based. Remember this should be support for which you did not pay.

OV10. Now I would like to ask you about the support your HH received for (Name).
In the last 12 months, has your HH received any medical support for (Name), such as
medical care, supplies or medicine?

OV11. In the last 12 months, has your HH received any emotional or psychological support for
(Name), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home?

OV12. Did your HH receive any of this support in the past 3 months?

OV13. In the last 12 months, has your HH received any material support for (Name), such as
clothing, food or financial support?

OV14. Did your HH receive any of this support in the past 3 months?

OV15. In the last 12 months, has your HH received any social support for (Name), such as help
in HH work, training for a caregiver, or legal services?

OV16. Did your HH receive any of this support in the past 3 months?

OV17. Check OV8: Age of the child 5-17 yr?

OV18. In the last 12 months, has your HH received any support for (name's) schooling, such
as allowance, free admission, books or supplies?

Insecticide-treated mosquito nets

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

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

TN2A. How many mosquito nets do you use for sleeping? If more than 7, record 7.

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:

Treated or pre-treated mosquito netting:

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

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

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.

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

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.

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.

Maternal mortality module: MM

Administer to each adult household member. Copy name and line number of each adult (age 15 or over) in the household. If one of these adults is not at home, another adult may respond for him/her. Indicate this by placing a '1' in MM3, and insert line number of proxy respondent in MM4. For household members below age 15, leave rows blank

MM1. Line no.

MM2. Name

MM3. Is this a proxy report?

MM4. Line no. of proxy respondent (from household listing HL1)

MM5. How many sisters (born to the same mother) have you ever had?

MM6. How many of these sisters ever reached age 15?

MM7. How many of these sisters (who are at least 15 years old) are alive now?

MM8. How many of these sisters who reached age 15 or more have died?

MM9. How many of these dead sisters died while pregnant, or during childbirth, or during the six weeks after the end of pregnancy?

Child discipline module: CD

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.

CD2. Line no. from HL1.

CD3. Name from HL2.

CD4. Sex from HL4.

CD5. Age from HL5.

CD6. Line no. of mother/caretaker from HL7 or HL8.

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

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.

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.

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

CD12C. Shook him/her.

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

CD12E. Gave him/her something else to do.

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

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

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

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

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

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

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

Disability: DA

To be administered to caretakers of all children 2 through 9 years old living in the household. For household members below age 2 or above age 9, leave rows blank
I would like to ask you if any children in this household aged 2 through 9 has any of the health conditions I am going to mention to you.

DA1. Line no.

DA2. Child's name

DA3. Compared with other children, does or did (name) have any serious delay in sitting, standing, or walking?

DA4. Compared with other children, does (name) have difficulty seeing, either in the daytime or at night?

DA5. Does (name) appear to have difficulty hearing? (uses hearing aid, hears with difficulty, completely deaf?)

DA6. When you tell (name) to do something, does he/she seem to understand what you are saying?

DA7. Does (name) have difficulty in walking or moving his/her arms or does he/she have weakness and/or stiffness in the arms or legs?

DA8. Does (name) sometimes have fits, become rigid, or lose consciousness?

DA9. Does (name) learn to do things like other children his/her age?

DA10. Is (name) able to speak like other children his/her age?

DA11. Does (name) way of speaking different from other children his/her age?

DA12. Can (name) name at least one object?

DA13. Does (name) seem mentally less developed compared to other children his/her age?

MODULE ON ANEMIA TEST (TA)

TA1. Check HH8A: Is this household selected for the men questionnaire and tests for anemia and HIV?
[] Yes (Continue with TA2)
[] No (Go to the next questionnaire)

TA2. Line number from column HL6 for women, HL6A for men, and HL6B for children under five _ _

TA3. Name for column HL2.

TA4. Age in column HL5

TA5. Check column TA4.

TA6. Register the line number for the parent/guardian responsible. Record '00' if it's not listed in the household questionnaire.

TA7. Read the consent form to the parent/guardian. Circle the code and sign.

TA8. Level of hemoglobin (G/DL) _ _

TA9. Current pregnant?

TA10. Result

TA11. Check TA8. Number of persons with hemoglobin levels that are less than the critical number.
None Give each woman/man/parent/adults the hemoglobin test results and continue with TA12.

TA12. We have detected a low level of hemoglobin in (your blood/child's blood). This
Means that (you/ name of child(ren)) are severely anemic, which is a serious health problem.
We wish to inform the doctor of (your/child's/children's name) about child/children's name). This will help you get the appropriate treatment for your condition. Do you agree that this information about the level of hemoglobin in (your blood/child's blood name of child/children) being released to the doctor?

Note: The critical threshold is 9 g/dl. for pregnant women and 7 g/dl. for children and women who are not pregnant (or who do not know if they are pregnant) (or who do not know if they are pregnant).
Note: If there is more than one woman or child below the critical threshold, read the TA12 statement to each woman who is below the critical threshold and to each woman/parent/caregiver responsible for the child who is below the critical threshold.

HIV Test (TH)

TH2. Line no.: _ _

TH4. Age in column HL5 or in column TA4
TH4. Verify the column TH4

TH6. Register the line number for the parent/guardian responsible. Record 00 if it's not listed in the household questionnaire.
TH7. Read the consent form to the parent/guardian.Circle the code and sign.

TH8. Read the consent form to the woman, the man, or the youth. Circle the code and sign.

TH9. Result

TH10. Barcode labels