MICS Household Questionnaire

[Central African Republic]
Household Information Panel: HH

HH1. Cluster number: _ _ _

HH2. Household number: _ _

HH2A. Selected for survey/interviewer:

HH3. Interviewer name and number:

HH4. Team leader name and number:

HH5. Day/month/year of interview

HH6. Area

HH7. Prefecture:

We are a team of interviewers from the Central African Institute of Statistics and Economic and Social Studies ("ICASEES"). We are working on a project concerned with family health and education. I would like to talk to you about these subjects. The interview will take about 45 minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team. 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. Result of household interview:

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: _ _

HH12A. Number of men age 15-49 years: _ _

HH13A. Number of men'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 clerk (name and number)

HH18. Record the time

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. Line number: _ _

HL2. Name: ____

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

HL4. Is (name) male or female?

HL5. What is (name's) date of birth?

HL6. How old is (name)?
Probe: How old was (name) on his/her last birthday? Record in completed years. If age is 95 or above record '95'
HL7. Circle line no.
If woman is age 15-49 (Eligibility for woman's interview)

HL7A. Circle line no.
If man is age 15-59 (Eligibility for man's interview)

HL8. For children age 5-17: Who is the mother or primary caretaker of this child?
Record line no. of mother/caretaker. Record 00 if independent. (mother or caretaker of child age 5-17.)
HL9. For children under age 5: Who is the mother or primary caretaker of this child?
Record line no. of mother/ caretaker (eligibility for under age 5)
HL10. Did (name) stay here last night?
(For all household members)
For children age 0-17 years ask questions HL11 to HL14

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

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

HL14. Does (name's) biological father live in this household?
Record line no. of father or 00 for "no"
[] tick here if additional questionnaire 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 employees, 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 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.

Code for HL3: Relationship to head of household

Education: ED

For household members age 5 and above [ED1 to ED4]

ED1. Line number: _ _

ED2. Name and age
Copy from Household Listing Form, HL2 and HL6
ED3. Has (name) ever attended school or pre-school?

ED4.What is the highest level of school (name) has attended? What is the highest grade (name) completed at this level?
If level=0, skip to ED5. If less than 1 grade, enter 00.
For household members age 5-24 years [ED5 to ED8]

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

ED6. During this/that school year, which level and grade is/was (name) attending?
If level=0, skip to ED7
ED7. During the previous school year, (2008-2009), did (name) attend school or preschool at any time?

ED8. During that previous school year, which level and grade did (name) attend?
If level=0, go to next person
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 can anyone use this facility?

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

Household characteristics: HC

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

HC1B. What ethnic group does the head of this household belong to?

HC1C. How far from your house is the closest school?
If "on site" or "less than 1 km", record 00.
HC1D. How far from your house is the closest health facility?
If "on site" or "less than 1 km", record 00.
HC2. How many rooms in this household are used for sleeping?

HC3. Main material of dwelling floor
Record observation
HC4. Main material of the roof
Record observations
HC5. Main material of the exterior walls.
Record observations
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 non-mobile telephone?

E. A refrigerator?

F. A generator?

G. A solar panel?

H. A table?

I. A tablet?

J. An armchair?

K. A chair?

HC9. Does any member of your household own:

A. A watch?

B. A mobile telephone?

C. A bicycle?

D. A motorcycle or scooter?

E. An animal drawn cart?

F. A car or truck?

G. A boat with a motor?

H. A rickshaw?

I. A sewing machine?

J. A brick press?

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".
HC11. Does any member of this household own any land that can be used for agriculture?

HC12. How many hectares 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'.
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, milk cows, or bulls?

B. Horses, donkeys, or mules?

C. Goats?

D. Sheep?

E. Chickens?

F. Pigs?

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

Insecticide Treated Nets: TN

TN1. Does your household have any mosquito nets that can be used while sleeping?

TN2. How many mosquito nets does your household have?

TN3. Ask the respondent to show you the nets in the household. If more than 3 nets, use additional questionnaire(s).
[Repeat questions from modules TN4-TN13 for each net]

TN4. Mosquito net observed

TN5. Observe or ask the brand/type of mosquito net.
If brand is unknown and you cannot observe the net, show pictures of typical net types/brands to respondent.
TN6. How many months ago did your household get the mosquito net?
If less than one month, record "00"
TN7. Check TN5 for type of net
TN8. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

TN9. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

TN10. How many months ago was the net last soaked or dipped?
If less than one month, record "00"
TN11. Did anyone sleep under this mosquito net last night?

TN12. Who slept under this mosquito net last night?
Record the person's line number from the household listing form
If someone not in the household list slept under the mosquito net, record 00
TN13.
1st Net: Go back to TN4 for next net. If no more nets, go to next module.
2nd Net: Go back to TN4 for next net. If no more nets, go to next module.
3rd Net: Go back to TN4 in first column of a new questionnaire for next net. If no more nets, go to next module.
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. Line number: _ _

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: Was he/she paid in cash or kind?
CL3A. What type of work was it?
[See codes below]

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.
CL7A. What type of work was it?
[See codes below]

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?

Child Discipline: CD

Table 1: Children Aged 2-14 Years Eligible for Child Discipline Questions
List each of the children aged 2-14 years below in the order they appear in the household listing form. Do not include other household members outside of the age range 2-14 years.
Record the line number, name, sex, and age for each child.
Then record the total number of children aged 2-14 in the box provided (CD6).
If there is only one child age 2-14 years in the household, then skip table 2 and go to CD8; write down'1' and continue with CD9.

CD1. Rank Number: _

CD2. Line number from HL1: _ _

CD3. Name from HL2: ____

CD4. Sex from HL4

CD5. Age from HL6: _ _

CD6. Total children age 2-14 years: _ _

Table 2: Random Selection of Child for Child Discipline Questions
Use Table 2 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.
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 eligible children (2-14) in CD6 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 (CD1) about whom the questions will be asked.

CD7.
Total number of eligible children in the household (CD6) [Column 1 to 8+]
Last digit of household number (HH2) [Row 0 to 9]

CD8. Record the rank number of the selected child: _

CD9. Write the name and line number of the child selected for the module from CD3 and CD2, based on the rank number in CD8.
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.
CD10. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

CD12. Explained to (name) why (name)'s behaviour was wrong.

CD13. Shook him/her.

CD14. Shouted, yelled at or screamed at him/her.

CD15. Gave him/her something else to do.

CD16. Spanked, hit or slapped him/her on the bottom with bare hand.

CD17. Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.

CD18. Called him/her dumb, lazy, or another name like that.

CD19. Hit or slapped him/her on the face, head or ears.

CD20. Hit or slapped him/her on the hand, arm, or leg.

CD21. Beat him/her up, that is hit him/her over and over as hard as one could.

CD22. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?

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 time

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.
HH20. Are there any eligible women age 15-49 who live in the household?
Check the household listing, column HL7 for each eligible woman. You should have a questionnaire with the information panel filled out for each eligible woman.
HH21. Are there any children under five who live in the household?
Check the household listing, column HL9 for each eligible child under 5.
You should have a questionnaire with the information panel filled out for each eligible
child.
HH21A. Was the household selected for a man's survey? (Check HH2A)?

Before leaving, thank the respondent for his/her cooperation. Gather up all the questionnaires for this household and record the number of completed questionnaires on the cover page.

Module on HIV Testing: TH

TH1. Check line number in column HL7 for women and HL7A for men in the household listing form. Record the line number, name, age, and sex of all women age 15-49 and all men age 15-59. This form must be destroyed in the office before the test results are added to the data base of the MICS survey.

TH2. Line number from column HL7 for women and HL7A for men: _ _

TH3. Name from column HL2: ____

TH4. Age from column HL6: _ _

TH5. Check column TH4.

TH6. Record the line number of parent/responsible adult.
Record '00' if not listed in household questionnaire.
TH7. Read the consent to parent/responsible adult.
Circle code and sign.
TH8. Read consent to woman, man, or young person.
Circle code and sign.
TH9. Test result

TH10. Barcode stickers.

Informed Consent Statement for HIV Testing

Informed consent for adults age 18 and older
Hello. My name is (your name) and I work for the Ministry of the Economy, Planning, and International Cooperation which is organizing this national survey on the health of women, men, and children.
As part of this survey, we are conducting a study of HIV/AIDS in women age 15 to 49 and in men age 15 to 59. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually deadly. We are doing the AIDS testing to measure how serious the problem of AIDS is in Central African Republic.
For the HIV testing, we are asking all eligible men and women from all over the country to give a few drops of blood from a finger. To get these drops, we will use sterile equipment and new supplies which are non-reusable. They were never used before you and will not be used after.
Next, the blood sample will be sent to a laboratory for analysis. No name will be noted or tied to the result. Therefore, we will not be able to give you the results of your test. Nor will anyone else be able to learn your test results. However, if you wish, I can give you a referral sheet to go to a Voluntary Testing Center for a free test.
Do you have any questions?
Now, do you agree to participate in this HIV testing?
Go to column TH8 and circle the appropriate code.

Informed consent for young people age 15-17
Step One: First ask informed consent of parent/responsible adult
The study of HIV/AIDS includes young men and women starting at age 15. For the HIV testing of these young people age 15 to 17, we are asking that their parent or responsible adult give their consent, as well as the young person. We are asking the young person, [Name], to participate in the HIV testing by giving us several drops of blood from a finger. To get these drops, we will use sterile equipment and new supplies which are non-reusable. They were never used before you and will not be used after.
Next, the blood sample will be sent to a laboratory for analysis. No name will be noted or tied to the result. Therefore, we will not be able to give you the results of your test. Nor will anyone else be able to learn your test results. However, if you wish, I can give [Name of young person] a referral sheet so that he/she can go to a Voluntary Testing Center for a free test.
Now, do you agree that [Name of young person] can participate in this HIV testing?
Go to column TH7 and circle the appropriate code.

Step Two: Informed consent of young person
If young person's parent/responsible adult has agreed that he/she can participate in the test, read the consent statement to the young person.
As part of this survey, we are conducting a study of HIV/AIDS in women age 15 to 49 and in men age 15 to 59. You may know that HIV is the virus that causes AIDS. AIDS is a serious illness, usually deadly. We are doing the AIDS testing to measure how serious the problem of AIDS is in Central African Republic.
For the HIV testing, we are asking all eligible men and women from all over the country to give a few drops of blood from a finger. To get these drops, we will use sterile equipment and new supplies which are non-reusable. They were never used before you and will not be used after.
Next, the blood sample will be sent to a laboratory for analysis. No name will be noted or tied to the result. Therefore, we will not be able to give you the results of your test. Nor will anyone else be able to learn your test results. However, if you wish, I can give you a referral sheet to go to a Voluntary Testing Center for a free test.
Now, do you agree to participate in this HIV testing?
Go to column TH8 and circle the appropriate code.

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ______