MICS Household Questionnaire

[Costa Rica]
Household Information Panel: HH

HH1. ID: _ _ _

HH2. Household number: _ _

HH3. Interviewer name and number

HH4. Supervisor name and number:

HH5. Day/month/year of interview

HH6. Area

HH7. Region

We are from Instituto Nacional de Estadística y Censos (INEC) [lit. National Institute for Statistics and Censuses]. 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 (number) 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 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: _ _

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 relation-ship of (name) to the head of household?

HL4. Is the (name) male or female?

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

HL6. How old is (name)?
Record in completed years. If age is 95 or above '95'
HL7. Circle line no.
If woman is age 15-49 (for woman age 15-49)

HL8. Who is the mother or primary caretaker of this child?
Record line no. of mother/caretaker (for children age 5-14.)
HL9. Who is the mother or primary caretaker of this child?
Record line no. of mother/ caretaker (for children under age 5)
For children age 0-17 years [HL11 to HL14]

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

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

HL14. Does (name's) natural father live in this household?
Record line no. of father or 00 for "no"
[] tick here is 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 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.

Code for HL3. Relationship to head of household

Education: ED

For household member age 5 and above [ED1 to ED4B]

ED1. Line number: _ _

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

ED4A. What is the highest level of school (name) has attended?
If level=0, skip to ED5
ED4B. What is the highest grade (name) completed at this level?
If less than 1 grade, enter 00
For household members age 5-24 years [ED5 to ED8]

ED5. During the (2011-2012) 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 ED5
ED7. During the previous school year, that is (2010-2011), 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, skip to ED5
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 is the facility open to the use of the general public?

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

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

HC1D. Was the head of the household born in Costa Rica?

HC1E. How long has the head of the household been living in Costa Rica?

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?

C1. Plasma, LCD, LED TV?

C1. Cable or satellite?

D. A non-mobile telephone?

E. A refrigerator?

F. Washing machine?

G. Own car?

H. Microwave oven?

I. Hot shower?

J. Boiler?

K. Water storage tank?

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. Desktop computer?

I. Laptop?

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?

Indoor residual spraying: IR

IR1. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

IR2. Who sprayed the dwelling?
Circle all that apply.
Child Labour: CL

To be administered for children in the household age 5-14 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 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: For pay in cash or kind?
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. During the past week did (name) beg for money on the streets?

CL8. Since last (day of the week), about how many hours did he/she do this work for his/her family or himself/herself?

CL8A. Since the last (day of the week), for approximately how many hours did (name) beg for money on the streets?

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?

CL11. During the past week, how many hours did (name) spend exclusively playing alone or with friends, having a walk, reading, listening to music or participating in recreational activities?

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 are no children age 2-14 years in the household, skip to next module.
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: Selection of Random 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.
CD10. 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.

CD11. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

CD12. Explained 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.
Skip to HH19 if any soap or detergent code (A, B, C or D) is circled. If "None" (Y) is circled, continue with HW4.
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

HH20. Are there eligible women between 15 to 49 years of age residing in the household?
Check the list of household members in column HL7 if there is an eligible woman. You must have a questionnaire with the completed Information Panel for each eligible woman.
HH21. Are there eligible children under 5 years of age residing in the household?
Check the list of household members in column HL9 if there is an eligible child. You must have a questionnaire with the completed Information Panel for each eligible child.

Gather all the corresponding questionnaires for this household and complete HH8 to HH15 in the cover.

Interviewer's observations ________

Field editor's observations ________

Supervisor?s observations ________