We are from the National Statistics Institute. We are working on a project on family health and education. I would like to talk to you about these topics. The interview will take a few minutes. All the information we collect will remain confidential according to the law number 91/023 of December 16, 1991 on censuses and statistical surveys which stipulates in its article 5 that "Individual economic or financial information contained in any statistical survey questionnaire may not be used for purposes of economic control or repression".
I would like to start 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.

HH7A.

HH8. Name of head of household: ____

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

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: _ _

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: _ _

HH16A. Date data was entered _ _ _ _ 2006

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
For people ages 10 and older:
HL5A. What is the marriage status of (name)?

HL6. Eligible for women's interview

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 between 18-59 years old:
HL8A. Was (name) very sick for at least three months of the last 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 this household: Was (name)'s mother very sick for at least three months of the last 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 this household: Was (name)'s father very sick for at least three months of the last 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?

For the members of the household attending preschool or primary school [ED6A-ED6F]

ED6A. During this school year, does (name) have a book for reading?

ED6B. How did (name) acquire this book?

ED6C.During this school year, did (name) have a book for math?

ED6D. How did (name) acquire this book?

ED6C.During this school year, did (name) have a book for science/scientific observations?

ED6D. How did (name) acquire this book?

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 (2004-2005), which level and grade did (name) attend?

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? _ _

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 behavior or to address a behavior 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).

CD12L. Isolate him/her, stop talking to him, lock him up, tie him up, put him on his knees.

CD12M. Refuse to give him/her food

CD12N. Make him/her recopy a text.

CD12O. Force him/her to eat a certain type of food or to make him/her eat more than usual

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

Module on children aged 2-9 with disabilities (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. Does (name) speak at all (can he/she make him or herself understood in words; can say any recognizable words)?

DA11. (For 3-9 year olds): Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?

DA12. (For 2-year-olds): Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?

DA13. Compared with other children of the same age, does (name) appear in any way mentally backward, dull or slow?

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?

WS3A. How far is the source of water from your house?

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?

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:










HC10. Does any member of your household own:









HC11. Does any member of this household own any land that can be used for agriculture?
[This question is from optional modules]

HC12. How many hectares of agricultural land do members of this household own?
[This question is from optional modules]
If more than 97, record '97'. If unknown, record '98'.
HC13. Does this household own any livestock, herds, or farm animals?
[This question is from optional modules]
HC14. How many of the following animals does this household have?
[This question is from optional modules]







HC15A. Do you or someone in this household own this dwelling, or do you rent this dwelling?

HC15B. Do you or someone in this household have a title deed for this dwelling?

HC15C. What kind of document do you have for the ownership of this dwelling?
Anything else?
Record all items mentioned.
HC15D. Do you have a written rental contract for this dwelling?

HC15E. Do you have any documentation or agreement for the rental of this dwelling? If yes, what kind of document or agreement do you have for the rental of this dwelling? Anything else?
Record all items mentioned.
HC15F. Do you feel secure from eviction from this dwelling?

HC15G. Have you been evicted from your home at any time during the past 5 years?

HC15H. Dwelling located in or near:
Observe, and circle all items that describe the location of dwelling.
HC15I. Condition of dwelling:
Record observation. Record all that apply.
HC15J. Dwelling surroundings:
Record observation. Record all that apply.
Source and cost of supplies for insecticide-treated mosquito nets

TN1. In your household, do you have mosquito netting that can be used for sleeping?

TN2. How many mosquito nets do you have in your household?
If more than 7, record 7.
TN2A. Check TN2: Number of mosquito nets.

TN2B. We are going to talk about each specific mosquito net separately starting with the one that was most recently obtained.
[Record answers for each individual net]

TN3. Does the mosquito net is one of the following types:
Read the name of each type and circle the corresponding code. If possible, ask the respondent to show you the net to verify the type.

Permanent mosquito nets :

Soaked mosquito nets :

Other mosquito nets :

TN3A. Where did you get each mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than
TN3B. How much did you pay for the mosquito net?

TN4.Check TN3. If the mosquito net is permanent or treated, Go to TN6.
If otherwise, continue with TN5.

TN5. When you obtained this net, was it treated with an insecticide made for killing or repelling mosquitos?

TN6. How long have you possessed this 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 this mosquito net, have you treated it or dipped it 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.
TN8A. Did someone sleep under this mosquito net last night?

TN8B. Who slept under this mosquito net last night?
Record the name and line number from the HH table. [Record up to 6 names.]
TN8C. Return to TN3 in the next column or if there are no more nets continue to the next module. If there are more than 4 nets, use an additional questionnaire.

Module 6: Children made vulnerable and orphaned by AIDS (OV)

OV1. Verify HL5: Are there any children aged 0-17?

OV2. I would like you to think about the last 12 months. Did a member of your household pass away in the last twelve months?

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

OV4. For those who passed away in the last 12 months and were aged 18-59 years old: were any of them extremely sick for at least 3 months of the 12 months prior to their death?

OV5. Return to the HH table and check the following:

OV8. List all children ages 0-17. Record the names, line numbers, and ages of all children, starting with the first child, and continue in the order in which they are listed in the household registration module. Use an additional questionnaire if there are more than 4 children aged 0-17 in the household. Ask any questions for one child before moving on to the next child.

OV9. I would like to ask you about any type of assistance or organized support your household may have received for (NAME) for which you did not pay. By organized help or support, I mean support provided by someone who works for a program, whether it be government private sector, religious, charitable or community-based program. It is important to remember that this is support for which you have not paid.

OV10. I would now like to ask you questions about the support your household has received for (name). in the past 12 months, did your household months, has your household received medical support for (name), such as care, supplies or medicines?

OV10A. Did your household receive any type of these supports in the last 3 months?

OV11. In the last 12 months, did your household receive moral or psychological support for (name) such as companionship, advice from a counselor, counseling, or spiritual support?

OV12. Did your household receive any type of these supports in the last 3 months?

OV13. In the last 12 months, did your house receive any material support for (name) such as clothes, food, or financial support?

OV14. Did your household receive any type of these supports in the last 3 months?

OV15. In the last 12 months, did your household receive social support for (name) such as help around the house, training to provide caregiving or assistance for administrative procedures?

OV16. Did your household receive any type of these supports in the last 3 months?

OV17. Verify OV8, the age of the child.

OV18. In the last 12 months months, did your household receive support for schooling from (name) as a scholarship, free tuition, books or books or supplies?

Module on household health expenditures (HE)

HE1. Please tell me if a member of the household is currently sick, suffering from a long term affliction/from an illness or has been suffering in the last 30 days.

HE2. Now i would like to ask you some questions about each person who has been sick or injured at some point in the last 30 days. please tell me the name of each. then we will about each one in detail, one at a time.
List all household members who have been sick in the last 30 days. Record the names, line numbers, and phone numbers of all members who have been sick, starting with the first member, and continue in the order in which they are listed on the
order in which they are listed on the household record sheet. Use an additional questionnaire if there are more than 3 sick people in the household. Ask all questions for one sick person before moving on to the next sick person.

HE2A. Number of sick people ?. __

HE3. Name and line number of person in HL1 and HL2

HE4. In your opinion, is (name)'s illness severe, moderate, or mild?

HE5. Has one looked to get a medical opinion or prescription to treat (name)'s illness?

HE6. Where did (name) seek medical attention?
If the respondent says "hospital", check the name and type of hospital or health center and circle the appropriate code in the following columns. If the respondent says "doctor", check if the patient has been to the doctor, or if the"doctor" has visited the patient's home (circle the corresponding code).
HE6A. What was the total amount of money spent to go to (healthcare place in HE6) and to return home?

HE7. What was the total amount of money spent for the healthcare consultation, healthcare (or hospitalization) at (healthcare place in HE6)?

HE8. What was the total amount of money spent on medicine and other prescribed products at (healthcare place in HE6)?

HE8A. What was the overall amount spent on the healthcare consultation, the medical care (or hospitalization), medicines, and other prescribed products at (healthcare place in HE6).

HE9. Was self-medication utilized?

HE10. Where did obtain medicine for the self-treatment of (name)?

HE11. What was the total amount spent on medicine for (name)'s self-treatment?

HE12. After the first visit to (healthcare place in HE6) was there a second consultation at the same place or did you look for another opinion/care elsewhere to take care of (name)'s injury or illness?

HE13. For this poor remedy, from whom was advice or a prescription sought for the illness/injury of (Name)?
If the respondent says "hospital", check the name and type of hospital or health center and circle the appropriate code in the following columns. If the respondent says "doctor", check if the patient has been to the doctor, or if the"doctor" has visited the patient's home (circle the corresponding code).
HE14.. What was the total amount of money spent to go to (healthcare place in HE13) and to return home?

HE15. What was the total amount of money spent for the healthcare consultation, healthcare (or hospitalization) at (healthcare place in HE13)?

HE16. What was the total amount of money spent on medicine and other prescribed products at (healthcare place in HE13)?

HE16A. What was the overall amount spent on the healthcare consultation, the medical care (or hospitalization), medicines, and other prescribed products at (healthcare place in HE13).

HE17 Filter. Check the answers to questions HE6A, HE7, HE8, HE8A, HE11, HE14, HE15, HE16, HE16A (in all the columns):
HE18. What was the total amount of the household's contribution in the expenses caused by (name)'s illness?

HE18A. Who is the person who contributed the most to the health expenses of (name)?
Respond with the name and the line number from HL1 and HL2. Answer '00' if not a member of household.
HE19. Where did (name from HE18A) find the money to pay for transport expenses, healthcare expenses, and medicine for (HE3)'s illness?
Anything else? Circle all answers.
HE19A. What was the financial source that provided the most funding?

HE19B. In the last 30 days, were there other curative health expenses for other illnesses?

HE19C. If yes, what was the total for the expenses in that case?

HE20. In the last 30 days, were there other expenses allotted for preventative healthcare (vaccination, medicine purchase, check-up, etc)?

HE21. If yes, what was the amount spent on preventative healthcare?

HE22. In the last 30 days, were there other healthcare expenses related to deceased household members or for visitors?

HE23. If yes, what was the amount spent on that?

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.

SI1A. Where do you keep your salt?

SI1B. How do you store your salt?

SI2. Does any eligible woman age 15-49 reside in the household?
Check household listing, column HL6. You should have a questionnaire with the information panel filled in for each eligible woman.
[] Yes (Go to questionnaire for individual women to administer the questionnaire to the first eligible woman)
[] No (Continue)

SI3. Does any child under the age of 5 reside in the household?
Check household listing, column HL8. You should have a questionnaire with the Information Panel filled in for each eligible child.
[] Yes (Go to questionnaire for children under five to administer the questionnaire to mother or caretaker of the first eligible child.)
[] No (End the interview by thanking the respondent for his/her cooperation.
Gather together all questionnaires for this household and tally the number of interviews completed on the cover page.)