Cuba

Household Information Panel: HH

1. Province: _ _

2. Municipality: _ _

3. Health area: _ _

4. Office: _ _

HH1. Office code: _ _ _

HH2. Household number: _ _

HH3. Interviewer name and number

HH4. Supervisor name and number:

HH5. Day/month/year of interview

HH6. Area

HH7. Region

HH8. Is the household selected for questionnaire for men?

We are from the Ministry of Public Health. 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 15 minutes. All the information we obtain will remain strictly confidential and anonymous. May I start now?

HH9. Result of household interview:

After the household questionnaire has been completed, fill in the following information:
HH10. Respondent to household questionnaire:

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: (if household is selected for questionnaire for men):_ _

After all questionnaires for the household have been completed, fill in the following information:
HH13B. Number of men's questionnaires completed: (if household is selected for questionnaire for men): _ _


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: _ _

HH16. Field editor's name and number:

HH17. Type by name and number:

HH18 Start of the interview

List of Household Members: 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, record '95':

For women age 15-49
HL7. Circle line no. If woman age 15-49 years old

HL7A. Circle line no. If man age 15-49 and the house-hold is selected for Questionnaire for men.

HL7B. Circle line no. If children age 0-4.

HL11. Is (name)'s natural mother alive
For children age 0-17 years
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?

HL13. Is (name)'s natural father alive

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?

HL15. Record line no. of mother from HL12 if indicated.
If HL12 is blank or '00' ask: who is the primary caretaker of (name)?
For children age 0-14
[] 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 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 woman, each eligible man, and each child under the age of 5 in the household.

Codes for HL3 Relation to head of household

Education: ED

ED1. Line number: _ _

ED2. Name and age
Copy from HL2 and HL6.
ED3. Has (name) ever attended school or pre-school?
For household members age 5 and above
ED4A. What is the highest level school (name) has ever attended?
For household members age 5 and above. If level=0, go directly to the next line or SL1 if you are the last person.
ED4B. What is the highest grade (name) completed at this level?
For household members age 5 and above. If the first grade at this level is not completed, enter "00".
Selection of a Child/for Child Discipline: SL

SL1. Check HL6 in the list of household members and write the total number of children in the age range of age 1-17 years.
SL2. Check the number of children age 1-14 years in SL1:
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

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.
SL9. Record the rank number (SL3), line number (SL4), name (SL5) and age (SL7) of the selected child.
Child Discipline: CD

CD2. Write the line number and name of the child from SL9.

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.

[B] Explained why (name)'s behaviour was wrong.

[C] Shook him/her.

[D] Shouted, yelled at or screamed at him/her.

[E] Gave him/her something else to do.

[F] Spanked, hit or slapped him/her on the bottom with bare hand.

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

[H] Called him/her dumb, lazy, or another name like that.

[I] Hit or slapped him/her on the face, head or ears.

[J] Hit or slapped him/her on the hand, arm, or leg.

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

CD4. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?

Water and Sanitation: WS

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

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

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 not possible to determine, 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?

Handwashing: HW

HW1. We would like to learn about where members of this household wash their hands. Can you please show me where members of your household most often wash their hands?

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
HW3A. Is soap, detergent or ash/sand present at the place for handwashing?

HW3B Record you observation
Circle all that apply
HW4 Do you have any soap or detergent or ash/mud/sand in your house for washing hands?

HW5A. Can you please show it to me?

HW5B Record your observation
Circle all that apply
HH19. The interview is over
HH20. Thank the respondent for his/her cooperation and check the list of household members:Check HH8. If the household is selected for questionnaire for individual men:

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), eligible men (HH13A), and under-5s (HH14) are entered. Make arrangements for the administration of the remaining questionnaire(s) in this household.

Interviewer's Observations ________

Field Editor's Observations ________

Supervisor's Observations ________