Name and year of survey

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. Region

HH8. Is the household selected for questionnaire for men?

HH9. Is the household selected for water quality testing?

HH10. Is the household selected for blank testing?

Check that the respondent is a knowledgeable member of the household and at least 18 years old before proceeding. You may only interview a child age 15-17 if there is no adult member of the household or all adult members are incapacitated. You may not interview a child under age 15.

HH11. Record the time.

HH12. Hello, my name is (your name). We are from [National Statistical Office]. We are conducting a survey about the situation of children, families and households. I would like to talk to you about these subjects. This interview usually takes about number minutes. Following this, I may ask to conduct additional interviews with you or other individual members of your household. All the information we obtain will remain strictly confidential and anonymous. If you do not wish to answer a question or stop the interview, please let me know. May I start now?

HH46. Result of household questionnaire interview:
Discuss any result not completed with supervisor.
HH47. Name and line number of the respondent to household questionnaire interview:

To be filled after the Household Questionnaire is completed
Total number

HH48. Household members: __ __


HH49. Women age 15-49: __ __

HH50. If household is selected for questionnaire for men:
Men age 15-49: __ __

HH51. Children under age 5: __ __

HH52. Children age 5-17: __ __

To be filled after all the questionnaires are completed
Completed number

HH53. Women age 15-49: __ __

HH54. If household is selected for questionnaire for men (men age 15-49): __ __

HH55. Children under age 5: __ __

HH56. Children age 5-17

[page 2]
List Of Household Members: HL

First complete HL2-HL4 vertically for all household members, starting with the head of the household. Once HL2-HL4 are complete for all members, make sure to probe for additional members: Those that are not currently at home, any infants or small children and any others who may not be family (such as servants, friends) but who usually live in the household.
Then, ask questions HL5-HL20 for each member one at a time. If additional questionnaires are used, indicate by ticking this box: ____

HL1. Line number: _ _

HL2. First, please tell me the name of each person who usually lives here, starting with the head of the household.
Probe for additional household members.
HL2A. Family number of (name).

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

HL4. Is (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".
HL6A. Is (name) 15 years or older?

HL6B. What is the current marriage status of (name)?

HL7. Did (name) stay here last night?

HL8. Record line number if woman and age 15-49: _ _

HL10. Record line number if age 0-4: _ _

HL11. Age 0-17?

HL12. Is (name)"s natural mother alive?

HL13. Does (name)'s natural mother live in this household?

HL14. Record the line number of mother and go to HL16: _ _

HL15. Where does (name)'s natural mother live?

HL16. Is (name)'s natural father alive?

HL17. Does (name)'s natural father live in this household?

HL18. Record the line number of father and go to HL20: _ _

HL19. Where does (name)'s natural father live?

HL20. Copy the line number of mother from HL14. If blank, ask: Who is the primary caretaker of (name)?
If "No one" for a child age 15-17, record "90".
Code for HL3. Relationship to head of household

[page 3]
Education 1: ED

ED1. Line number: _ _

ED2. Name and age
Copy names and ages of all members of the household from HL2 and HL6 to below and to next page of the module.
ED3. Age 3 or above?

ED4. Has (name) ever attended school or any early childhood education programme?

ED5. What is the highest level and grade or year of school (name) has ever attended?

ED6. Did (name) ever complete that (grade/year)?

ED7. Age 3-24?

ED8. Check ED4: Ever attended school or ECE?
[page 4]
Education 2: ED

ED1. Line number _ _

ED2. Name and age

ED9. At any time during the current school year (2018-2019) did (name) attend school or any early childhood education programme?

ED10. During this current school year (2018-2019), which level and grade or year is (name) attending?

ED11. Is (he/she) attending a public school?
If "Yes", record "1". If "No", probe to code who controls and manages the school.
ED12. In the current school year (2018-2019), has (name) received any school tuition support?
If "Yes", probe to ensure that support was not received from family, other relatives, friends or neighbours.
ED13. Who provided the tuition support?
Record all mentioned.
ED14. For the current school year (2018-2019), has (name) received any material support or cash to buy shoes, exercise books, notebooks, school uniforms or other school supplies?
If "Yes", probe to ensure that support was not received from family, other relatives, friends or neighbours.
ED14A. For the current 2018-2019 school year, did (name) benefit from school transport?

ED14B. For the current 2018-2019 school year, did (name) benefit from the school cafeteria?

ED15. At any time during the previous school year (2017-2018) did (name) attend school or any early childhood education programme?

ED16. During that previous school year (2017-2018), which level and grade or year did (name) attend?

ED16C. Currently in school? ED9=1

ED16D. Aged between 16-24 years old?

ED16E. Has (name) attended an establishment for professionalization formations?

ED16F. Aged between 16-24 years old?

[page 5]
Household Characteristics: HC

HC0A. What was this unit completed?

HC0B. In total, including yours, how many households live in this dwelling?

HC1C. Type of building where the household lives:
Record the observation.
HC1D. How many rooms are in your house (not including bathrooms and the kitchen)?

HC3. How many rooms do members of this household usually use for sleeping?

HC4. Main material of the dwelling floor.
Record observation. If observation is not possible, ask the respondent to determine the material of the dwelling floor.
[page 6]
HC5. Main material of the roof.
Record observation.

HC6. Main material of the exterior walls.
Record observation.
HC7. Does your household have:

A. A fixed telephone line?

B. A radio?

C. A living room?

D. A dining room?

E. A library?

F. A water heater (gas)?

C. Heat (gas)?

HC8. Does your household have electricity?

HC8A. Do you have an electric meter?

[page 7]
HC9. Does your household have:

A. A television?

B. A refrigerator?

C. Freezer

D. Laundry Machine

E. Dishwasher

F. Air conditioner

G. Vacuum cleaner

H. Satellite receiver with internet (demo)?

I. Microwave?

J. Hair dryer

K. Iron

L. Blender

M. Printer

N. Suppressor

O. Intercom

P. Oil bath

Q. Electric heater

HC10. Does any member of your household own:

A. A wristwatch?

B. A bicycle?

C. A motorcycle or scooter?

D. An animal-drawn cart?

E. A car, truck or van?

F. A boat with a motor?

G. Country specific items
(See customization guidelines)
HC11. Does any member of your household have a computer or a tablet?

HC11A. Does a member of your household have a touchscreen tablet?

HC12. Does any member of your household have a mobile telephone?

HC12A. Does a member of your household have a smartphone?

HC13. Does your household have access to internet at home?

HC13A. What is the main type of connection for the internet?

HC13B. Check HC11A and HC12A.

If HC11A and/or HC12A =1, continue with HC13C. If not, go to HC14.


HC13C. Has a member of your household been able to access mobile internet (3G/4G) on their cell phone or tablet?

HC14. 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", record "2". For other responses, record "6" and specify.
HC14A. Have you or any member of your household received any state assistance in the provision of this housing? If yes, which one?

HC14B. Do you or any member of your household own a piece of land for development?

HC14C. Are you or any member of your family going to build a home?

HC14D. Are you or any member of your household able to receive state assistance for the construction of this housing?

HC14E. Have you or any member of your household applied to the state's specialized services for assistance to construct the house?

HC14F. Have you or any member of your household applied to specialized state services for housing?

HC15. Does any member of this household own any land that can be used for agriculture?

HC16. How many hectares of agricultural land do members of this household own?
If less than 1, record "00".
HC17. Does this household own any livestock, herds, other farm animals, or poultry?

[page 8]
HC18. 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. Milk cows or bulls?

C. Horses, donkeys or mules?

D. Goats?

E. Sheep?

F. Chickens?

H. Rabbits

I. Camels

HC19. Does any member of this household have a bank account?

[page 9]
Social Transfers: ST

ST1. I would like to ask you about various external economic assistance programmes provided to households. By external assistance I mean support that comes from the government or from non-governmental organizations such as religious, charitable, or community-based organizations. This excludes support from family, other relatives, friends or neighbours.

ST2. Are you aware of (name of programme)?

ST3. Has your household or anyone in your household received assistance through (name of programme)?

ST4. When was the last time your household or anyone in your household received assistance through (name of programme)?
If less than one month, record "1" and record "00" in Months. If less than 12 months, record "1" and record in Months. If 1 year/12 months or more, record "2" and record in Years.
[page 10]
Household Energy Use: EU

EU1. In your household, what type of cookstove is mainly used for cooking?

EU2. Does it have a chimney?

EU3. Does it have a fan?

EU4. What type of fuel or energy source is used in this cookstove?
If more than one, record the main energy source for this cookstove.
EU5. Is the cooking usually done in the house, in a separate building, or outdoors?
If in main house, probe to determine if cooking is done in a separate room. If outdoors, probe to determine if cooking is done on veranda, covered porch, or open air.
[page 11]
EU6. What does your household mainly use for space heating when needed?

EU7. Does it have a chimney?

EU8. What type of fuel and energy source is used in this heater?
If more than one, record the main energy source for this heater.
[page 12]
EU9. At night, what does your household mainly use to light the household?

[page 13]
Insecticide treated nets: TN

TN1. Does your household have any mosquito nets?

TN2. How many mosquito nets does your household have?

TN3. Ask the respondent to show you all the nets in the household. [Up to three nets]

TN4. How many months ago did your household get the mosquito net? [Up to three nets]
If less than one month, record "00".
TN5. Observe or ask the brand/type of mosquito net. [Up to three nets]
If brand is unknown and you cannot observe the net, show pictures of typical net types/brands to respondent.

TN10. Did you get the net through a local name of mass distribution campaign, during an antenatal care visit, or during an immunization visit? [Up to three nets]

TN11. Check TN10: Is TN10=4 or 8? [Up to three nets]
[page 14]
TN12. Where did you get the net? [Up to three nets]

TN13. Did anyone sleep under this mosquito net last night?[Up to three nets]

TN14. Check TN13: Did anyone sleep under the net (TN13=1)? [Up to three nets]

TN15. Who slept under this mosquito net last night? [Up to three nets]
Record the person"s line number from the list of household members. If someone not in the list of household members slept under the mosquito net, record "00".
TN16. Is there another net? [Up to three nets]

[] Tick here if additional questionnaire used

[page 15]
Water and sanitation: WS

WS0A. Is your household connected to a source of drinkable water?

WS0B. Do you have a water meter?

WS1. What is the main source of drinking water used by members of your household?
If unclear, probe to identify the place from which members of this household most often collect drinking water (collection point).
WS2. What is the main source of water used by members of your household for other purposes such as cooking and handwashing?
If unclear, probe to identify the place from which members of this household most often collect water for other purposes.
[page 16]
WS3. Where is that water source located?

WS4. How long does it take for members of your household to go there, get water, and come back?

WS5. Who usually goes to this source to collect the water for your household?
Record the name of the person and copy the line number of this person from the list of household members module.

WS6. Since last (day of the week), how many times has this person collected water?

WS7. In the last month, has there been any time when your household did not have sufficient quantities of drinking water?

WS8. What was the main reason that you were unable to access water in sufficient quantities when needed?

WS9. Do you or any other member of this household do anything to the water to make it safer to drink?

[page 17]
WS10. What do you usually do to make the water safer to drink?
Probe: Anything else?
Record all methods mentioned.
WS10A. What type of tank do you use to store/hold water? Record all types of tanks used by the household.

WS11. 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.
WS12. Has your (answer from WS11) ever been emptied?

WS13. The last time it was emptied, where were the contents emptied to?
Probe: Was it removed by a service provider?
[page 18]
WS14. Where is this toilet facility located?

WS15. Do you share this facility with others who are not members of your household?

WS16. 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?

WS17. How many households in total use this toilet facility, including your own household?

[page 19]
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?
Record result and observation.
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.
HW3. Is soap or detergent or ash/mud/sand present at the place for handwashing?

HW4. Where do you or other members of your household most often wash your hands?

HW5. Do you have any soap or detergent or ash/mud/sand in your house for washing hands?

HW6. Can you please show it to me?

HW7. Record your observation.
Record all that apply.
[page 20]
Salt Iodisation: SA

SA1. We would like to check whether the salt used in your household is iodised. May I have a sample of the salt used to cook meals in your household?
Apply 2 drops of test solution, observe the darkest reaction within 30 seconds, compare to the colour chart and then record the response (1, 2 or 3) that corresponds to test outcome.
SA2. I would like to perform one more test. May I have another sample of the same salt?
Apply 5 drops of recheck solution. Then apply 2 drops of test solution on the same spot. Observe the darkest reaction within 30 seconds, compare to the colour chart and then record the response (1, 2 or 3) that corresponds to test outcome.
SA2A. Do you buy salt when shopping?

HH13. Record the time.

HH14. Language of the Questionnaire.

HH15. Language of the Interview.

HH16. Native language of the Respondent.

HH17. Was a translator used for any parts of this questionnaire?

HH18. Check HL6 in the "List of household members" and indicate the total number of children age 5-17 years:
[page 21]
HH19. List each of the children age 5-17 years below in the order they appear in the list of household members. Do not include other household members outside of the age range 5-17 years. Record the line number, name, sex, and age for each child.

HH20. Rank number: _

HH21. Line number from HL1: _ _

HH22. Name from HL2: ____

HH23. Sex from HL4

HH24. Age from HL6: _ _

HH25. Check the last digit of the household number (HH2) from the household information panel. This is the number of the row you should go to in the table below.
Check the total number of children age 5-17 years in HH18 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 record the number that appears in the box. This is the rank number (HH20) of the selected child.

HH26. Record the rank number (HH20), line number (HH21), name (HH22) and age (HH24) of the selected child.

HH27. (When HH18=1 or when there is a single child age 5-17 in the household): Record the rank number as "1"and record the line number (HL1), the name (HL2) and age (HL6) of this child from the list of household members.

HH28. Issue a questionnaire for children age 5-17 to be administered to the mother/caretaker of this child.

[page 22]
HH29. Check HL8 in the list of household members: Are there any women age 15-49?
HH30. Issue a separate questionnaire for individual women for each woman age 15-49 years.

HH31. Check HL6 and HL8 in the list of household members: Are there any girls age 15-17?
HH32. Check HL20 in the list of household members: Is consent required for interviewing at least one girl age 15-17?
HH33. As part of the survey we are also interviewing women age 15-49. We ask each person we interview for permission. A female interviewer conducts these interviews.
For girls age 15-17 we must also get permission from an adult to interview them. As mentioned before, all the information we obtain will remain strictly confidential and anonymous.
May we interview (name(s) of female member(s) age 15-17) later?

HH40. Check HL10 in the "List of household members": Are there any children age 0-4?
HH41. Issue a separate questionnaire for children under five for each child age 0-4 years.

HH42. Check HH9 in the household information panel: Is the household selected for water quality testing questionnaire?
HH43. Issue a separate water quality testing questionnaire for this household

HH44. As part of the survey we are also looking at the quality of drinking water. We would like to do a simple test of your drinking water. A colleague will come and collect the water samples. May we do such a test?
If the respondent requests to learn the results, explain that results will not be shared with individual households but will be made available to local authorities.
HH45. Now return to the household information panel and,
Record "01" in question HH46 (Result of the Household Questionnaire interview). Record the name and the line number (from the list of household members) of the respondent to the household questionnaire interview in HH47. Fill the questions HH48 ? HH52. Thank the respondent for his/her cooperation and then proceed with the administration of the remaining individual questionnaire(s) in this household.
If there is no individual questionnaire and no water quality testing questionnaire to be completed in this household thank the respondent for his/her cooperation and move to the next household you have been assigned by your supervisor.

[page 24]
Interviewer's Observations ________

Supervisor's Observations ________

Economic Activity (AE)

AE1. Line number

AE2. Name and age.
Copy names and ages of all the members of the household from HL2 and HL6, below and on the next page of the module.
AE3. 15 years or older?

AE4. What is the job situation of (name) during the 30 days preceding the date of the interview?

AE5. What is (name)?s financial situation in this profession?

AE6. Does (name) work in the public or private sector?

AE7. Is (name) affiliated with a social insurance fund? Including: CNAS, CASNOS, CAMSSP.

AE8. Does the current employment of (name) fall within the scope of state aid?
(0, 1, 2, 3, 4, 5 or 8) Go to AE12.
AE9. Is (name) on scholarship?

AE10. Has (name) registered with the ANEM?

AE11. Does (name) receive assistance from the state?

AE12. Does (name) have a chiffa card ?

Household Waste

DM1. Where do you keep the waste (bags, garbage cans, etc)?

DM2. How often do you dispose of household waste?

DM3. How do you dispose of household waste?

DM4. What do you do with unused medications that are past their expiration date and that are not yet expired?

DM5. How do you dispose of unused/expired medications?

DM6. What do you do with used syringes and needles (insulin syringes, etc.)?

DM7. Survey Instructions: Observe and circle the appropriate box. Is the area around the dwelling mostly clean and dry, or is there garbage or STAGNANT WATER around the dwelling?
If code "A" is circled, no other modality should be circled.
Chronic Diseases (People Aged 15 Years and Over)

MC1. Number of line.

MC2. Name and age:
Copy the names and ages of all household members from HL2 and HL6, below and on the next page of this module
MC3. 15 years of age or older?

MC4. Does (name) have a chronic illness?

MC5. What illness does he/she have?

MC6. Has this disease been diagnosed by a doctor?

MC7. What age was (name) when this disease was diagnosed by the doctor?

MC8. Does (name) follow a treatment for this illness?

MC9. Does (name) have a second chronic illness?

MC10. What illness does he/she have?

MC11. Has this disease been diagnosed by a doctor?

MC12. Does (name) follow a treatment for this illness?

MC13. Does (name) use a Chiffa card for this chronic illness?

General Mortality

MG1. During the past 5 years i.e. since January 2013, has there been a member of this household who has died?

MG2. How many members have died since January 2013?

MG3. No. of order:

MG4. Can you give me the name(s) and surname(s) of the member(s) (see MG2) who died?

MG5. What is the relationship of (name) to the (current) head of household?

MG6. (Name) is male or female?

MG7. What is the date of birth of (name)?

MG8. What is the date of death of (name)?

MG9. Where did (name) die?

MG10. Was the death of (name) registered at the civil registry office?