MICS Household Questionnaire
Algeria

Household Information Panel: HH

HHA. Province ______

HHB. Commune ______

HH1. Cluster number: _ _ _

HH6. Area:

HH2. Household number: _ _

HH3. Interviewer name and number

HH4. Field editor name and number:

HH5. Day/month/year of interview

We are from the Ministry of Health, Population, and Hospital Reform. 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 90 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?

HH8. Full name of head of household: ____

HH9. Final result of household interview:

Summary Table

HH10. Name of 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: _ _

Office Control and Verification Table
HH16. Field edited by (name and number)

HH17. Date entry clerk (name and number)

HH18. Record the time at beginning of interview

Module 1: 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. Full name: ____

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

Code for HL3. Relationship to head of household

HL4. Sex of (name)

HL5. What is (name's) date of birth?
Record day, month and year of birth.

HL6. How old was (name) on his/her last birthday?
Record in completed years. If age is 95 or above, record '95'
HL6A. What is (name)'s marital status? (if age 15 or older)

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, and each child under five in the household.

HL7. Circle line no. of all women age 15 to 49

HL8. Who is the mother or primary caretaker of this child?
Record line no. of mother/caretaker (for children age 5-15.)
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) biological mother alive?

HL12.
Record line number of mother if she lives in household. If not, record 00
HL13. Is (name's) biological father alive?

HL14. Record line number of father if he lives in household. If not, record 00
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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.
[] tick here if additional questionnaire used.

Module 2: Education: ED

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

ED1. Line number: _ _

ED2.Full name and age
Copy from 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 no grade successfully completed, enter 00
For household members age 5-24 years [ED5 to ED8]

ED5. During the (2012-2013) school year, did (name) attend school or preschool at any time?

ED6. Which level and grade is/was (name) attending?
If level=0, skip to ED7
ED7. During the previous school year, that is (2011-2012), did (name) attend school or preschool?

ED8. Which level and grade did (name) attend?
If level=0, skip to next line
Module 3: Economic Activity of people age 15 and older: AC

AC1. Line number ______

AC1A. Full name (copy from HL2) ______

AC2. What has (name)'s personal employment situation been in the last month?

For those who are employed (AC2 = 1) AC3 - AC5

AC3. What is his/her position in the profession?

AC4. What is the branch of activity of the establishment where (name) works?

AC5. In what sector is the establishment where (name) works?

Module 4: Chronic illnesses (people age 15 and older) MC

MC1. Does (name) suffer from a chronic illness?

MC2. What illness does he/she suffer from?

MC3. Was this illness diagnosed by a physician?

MC4. How many years ago was this illness diagnosed by a physician?

MC5. Does (name) suffer from another chronic disease?

MC6. What illness does he/she suffer from?

MC7. Was this illness diagnosed by a physician?

Module 5: Handicap. HD

HD1. Does one or more household member have a physical or mental state which has lasted 6 months or more, which prevents member or limits participation in normal activities for a person that age?

HD2. How many household members present with this condition?

Interviewer: Record the full name and the line number of each person stated as being handicapped in HA3, then ask questions HA4 to HA8.

HD3. Can you give me the names of the people who present this physical or mental handicap?

HD4. Does (name)'s state limit him/her severely or moderately?

HD5. Does (name) have an impairment in any of the following functions?

HD6. Which of the following best describes the reason for (name)'s condition?

HD7. Does the disability cited cause (name) to be unable to accomplish:

HD8. How old was (name) when this condition began?

Module 6: Water and Sanitation WS

WS1A. Is your dwelling connected to a drinking-water system?

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 cooking and handwashing?

WS3. Where is that water source located?

WS4. How long does it take to go there, get water, and come back?
Estimate time in minutes.

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.
WS8A. Do you have a toilet?
If yes: Is it inside or outside the dwelling?

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?

Module 7: Household characteristics: HC

HC1D. Type of dwelling occupied by household.
Record observation.
HC2. How many rooms in this household are used for sleeping?

HC3. Main material of 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?

HC7A. What type of lighting do you have?

HC8. Does your household have:

A. Electricity?

B. A radio?

C. A television?

D. A non-mobile telephone?

E. A refrigerator?

F. A satellite dish?

G. A stovetop?

H. A washing machine?

I. A water heater?

J. Gas or electric heat?

K. An air conditioner?

L. A computer?

M. Internet connection?

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?

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?

G. Camels?

H. Rabbits?

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

Module 8: General Mortality GM

MG1. In the last 5 years, has any household member died?

MG2. How many household members have died in the last 5 years?

Interviewer: Record the name of all people who died in the last 5 years in MG4, then ask questions MG5 to MG10 for each person.

MG3. Order number ______

MG4. Full name ______

MG5. What was his/her relationship to the current head of household? ______
Codes for MG5: Relationship to current head of household.

MG6. Sex

MG7. Birthdate of deceased

MG8. Date of death

MG9. Place of death

MG10. Was the death registered with the civil authorities?

Module 9: Child Labour: CL

To be administered for children in the household age 5-15 years. Questions must be asked of the mother or caretaker for each child living in the household age 5-15 years.
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?
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.
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?

Module 10: Child Discipline: CD

Table 1: Children Aged 2-14 Years Eligible for the module: Child Discipline.
The above table, the line number, name, sex, age and mother's or caretaker's line number of any child living in the household between age of 2 and 14.

CD1. Rank Number: _

CD2. Line number from HL1: _ _

CD3. Full Name of child from HL2: ____

CD4. Sex from HL4

CD5. Age of child from HL6: _ _

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

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
Table 2: Random selection of Child for Child Discipline Questions
Use this table to select one child between the ages of 2 and 14 years, if there are several children 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.
Record the rank of selected child in question CD8 below. Record the name and number of child in the box of variable CD9 on the following page.
CD7. Total number of eligible children in the household [Column 1 to 8+]
Last digit of household number (HH2) [Row 0 to 9]

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

Full name of child ______

CD9. Line number of the child selected
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, 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?

Module 11: Accidents AC

This module is for children in the household under the age of 15.

AC1A. Are there one or more members of the household under the age of 15 who have been victims of a serious accident in their life?

AC1. Line number (HL1) ______

AC2. Name and age
Can you please give me the name of people who have been victims of a serious accident?
Copy age from HL6.
AC3. How many times has (name) been the victim of a serious accident?
Record the number of times.
AC4. What type of accident (or last accident) did (name) have?

AC5. How old was (name) when this accident (the last accident) happened?

AC6. What is the cause of this accident (of this last accident)?

AC7. Where did this accident (this last accident) occur?

AC8. Where was (name) taken?

AC9. Why wasn't (name) cared for in a hospital or by a doctor?

Module 12: 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 no 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 cleansing agents in your household for washing hands?

HW5. Can you please show it to me?
Record observation. Circle all that apply.
HH19. Record the time at the end of the interview

Module 13: Salt Iodization: SI

SI1. 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.
SI1A. Did you buy this salt from a shop?

HH20. Thank the respondent for his/her cooperation and check the Household Listing Form:

Return to the cover page and make sure that all information is entered, including the number of eligible women (HH12) and children under-5 (HH14).
Make arrangements for the administration of the remaining questionnaire(s) in this household.

Interviewer's observations ________

Field editor's observations ________
Supervisor's observations ______