MICS 6: Household Questionnaire
Name and year of survey
Household Information Panel: HH
HH1. Cluster number: _ _ _
HH2. Household number: _ _
HH3. Interviewer name and number:
Name ____
Number _ _
Number _ _
HH4. Supervisor name and number:
Name ____
Number _ _
Number _ _
HH5. Day/Month/Year of interview:
_ _/_ _ /201 _
HH6. Area
[] 1 Urban
[] 2 Rural
[] 2 Rural
HH7. Region
[] 1 NORD CENTRE
[] 2 NORD EST
[] 3 NORD OUEST
[] 4 HAUT PLATEAU CENTRE
[] 5 HAUT PLATEAU EST
[] 6 HAUT PLATEAU OUEST
[] 7 SUD
[] 2 NORD EST
[] 3 NORD OUEST
[] 4 HAUT PLATEAU CENTRE
[] 5 HAUT PLATEAU EST
[] 6 HAUT PLATEAU OUEST
[] 7 SUD
HH8. Is the household selected for questionnaire for men?
[] 1 Yes
[] 2 No
[] 2 No
HH9. Is the household selected for water quality testing?
[] 1 Yes
[] 2 No
[] 2 No
HH10. Is the household selected for blank testing?
[] 1 Yes
[] 2 No
[] 2 No
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.
_ _ Hour
_ _ Minutes
_ _ Minutes
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?
[] Yes (List of household members)
[] No/not asked (Go to HH46)
[] No/not asked (Go to HH46)
HH46. Result of household questionnaire interview:
Discuss any result not completed with supervisor.
[] 01 Completed
[] 02 No household member or no competent respondent at home at time of visit
[] 03 Entire household absent for extended period of time
[] 04 Refused
[] 05 Dwelling vacant or address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
[] 02 No household member or no competent respondent at home at time of visit
[] 03 Entire household absent for extended period of time
[] 04 Refused
[] 05 Dwelling vacant or address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
HH47. Name and line number of the respondent to household questionnaire interview:
Name ____
Line number _ _
Line number _ _
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
[] 0 Zero
[] 1 One
[] 1 One
[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.
Name: ____
HL2A. Family number of (name).
Family: ____
HL3. What is the relationship of (name) to (name of the head of household)?
Relation: _ _
HL4. Is (name) male or female?
[] 1 Male
[] 2 Female
[] 2 Female
HL5. What is (name)'s date of birth?
Month: _ _
[] 98 DK
Year: _ _ _ _
[] 9988 DK
[] 98 DK
Year: _ _ _ _
[] 9988 DK
HL6. How old is (name)?
Record in completed years.If age is 95 or above, record "95".
Age _ _
HL6A. Is (name) 15 years or older?
[] 1 Yes
[] 2 No (Go to HL10)
[] 2 No (Go to HL10)
HL6B. What is the current marriage status of (name)?
[] 1 Single
[] 2 Married
[] 3 Divorced
[] 4 Separated
[] 5 Widowed
[] 2 Married
[] 3 Divorced
[] 4 Separated
[] 5 Widowed
HL7. Did (name) stay here last night?
[] 1 Yes
[] 2 No
[] 2 No
HL8. Record line number if woman and age 15-49: _ _
HL10. Record line number if age 0-4: _ _
HL11. Age 0-17?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
HL12. Is (name)"s natural mother alive?
[] 1 Yes
[] 2 No (Go to HL16)
[] 8 DK (Go to HL16)
[] 2 No (Go to HL16)
[] 8 DK (Go to HL16)
HL13. Does (name)'s natural mother live in this household?
[] 1 Yes
[] 2 No (Go to HL15)
[] 2 No (Go to HL15)
HL14. Record the line number of mother and go to HL16: _ _
HL15. Where does (name)'s natural mother live?
[] 1 Abroad
[] 2 In another household in the same region
[] 3 In another household in another region
[] 4 Institution in this country
[] 8 DK
[] 2 In another household in the same region
[] 3 In another household in another region
[] 4 Institution in this country
[] 8 DK
HL16. Is (name)'s natural father alive?
[] 1 Yes
[] 2 No (Go to HL20)
[] 8 DK (Go to HL20)
[] 2 No (Go to HL20)
[] 8 DK (Go to HL20)
HL17. Does (name)'s natural father live in this household?
[] 1 Yes
[] 2 No (go to HL19)
[] 2 No (go to HL19)
HL18. Record the line number of father and go to HL20: _ _
HL19. Where does (name)'s natural father live?
[] 1 Abroad
[] 2 In another household in the same region
[] 3 In another household in another region
[] 4 Institution in this country
[] 8 DK
[] 2 In another household in the same region
[] 3 In another household in another region
[] 4 Institution in this country
[] 8 DK
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".
Number: _ _
Code for HL3. Relationship to head of household
[] 01 Head
[] 02 Spouse/partner
[] 03 Son/daughter
[] 04 Son-in-law/daughter-in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother/sister
[] 09 Brother-in-law/sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew
[] 12 Other Relative
[] 13 Adopted/foster/stepchild
[] 14 Servant (live-in)
[] 96 Other (not related)
[] 98 Don't Know
[] 02 Spouse/partner
[] 03 Son/daughter
[] 04 Son-in-law/daughter-in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother/sister
[] 09 Brother-in-law/sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew
[] 12 Other Relative
[] 13 Adopted/foster/stepchild
[] 14 Servant (live-in)
[] 96 Other (not related)
[] 98 Don't Know
[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.
Name: ____
Age: _ _
Age: _ _
ED3. Age 3 or above?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
ED4. Has (name) ever attended school or any early childhood education programme?
[] 1 Yes
[] 2 No (Go to ED16D)
[] 2 No (Go to ED16D)
ED5. What is the highest level and grade or year of school (name) has ever attended?
Level
[] 0 ECE (Go to ED7)
[] 1 Primary
[] 2 Lower secondary
[] 3 Upper secondary
[] 4 Higher
[] 8 DK
[] 1 Primary
[] 2 Lower secondary
[] 3 Upper secondary
[] 4 Higher
[] 8 DK
Grade/year:
[] 98. DK (Go to ED7)
ED6. Did (name) ever complete that (grade/year)?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
ED7. Age 3-24?
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
ED8. Check ED4: Ever attended school or ECE?
[] 1 Yes
[] 2 No ( Go to ED16D)
[] 2 No ( Go to ED16D)
[page 4]
Education 2: ED
ED1. Line number _ _
ED2. Name and age
Name: ____
Age: _ _
Age: _ _
ED9. At any time during the current school year (2018-2019) did (name) attend school or any early childhood education programme?
[] 1 Yes
[] 2 No (Go to ED15)
[] 2 No (Go to ED15)
ED10. During this current school year (2018-2019), which level and grade or year is (name) attending?
Level
[] 1 Primary
[] 2 Lower sec.
[] 3 Upper sec.
[] 4 Higher
[] 8 DK
[] 2 Lower sec.
[] 3 Upper sec.
[] 4 Higher
[] 8 DK
Grade/year:
[] 98. DK
ED11. Is (he/she) attending a public school?
If "Yes", record "1". If "No", probe to code who controls and manages the school.
[] 1 Public
[] 2 Private
[] 6 Other
[] 8 DK
[] 2 Private
[] 6 Other
[] 8 DK
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.
[] 1 Yes
[] 2 No (Go to ED14)
[] 8 DK (Go to ED14)
[] 2 No (Go to ED14)
[] 8 DK (Go to ED14)
ED13. Who provided the tuition support?
Record all mentioned.
[] A Public
[] B Private
[] D Association
[] X Other
[] Z DK
[] B Private
[] D Association
[] X Other
[] Z DK
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.
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
ED14A. For the current 2018-2019 school year, did (name) benefit from school transport?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
ED14B. For the current 2018-2019 school year, did (name) benefit from the school cafeteria?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
ED15. At any time during the previous school year (2017-2018) did (name) attend school or any early childhood education programme?
[] 1 Yes
[] 2 No (Go to ED16C)
[] 8 DK (Go to ED16C)
[] 2 No (Go to ED16C)
[] 8 DK (Go to ED16C)
ED16. During that previous school year (2017-2018), which level and grade or year did (name) attend?
Level
[] 0 ECE (Go to next line)
[] 1 Primary
[] 2 Lower sec
[] 3 Upper sec
[] 4 Higher
[] 8 DK
[] 1 Primary
[] 2 Lower sec
[] 3 Upper sec
[] 4 Higher
[] 8 DK
Grade/Year:
[] 98. DK
ED16C. Currently in school? ED9=1
[] 1 Yes (Go to next line)
[] 2 No
[] 2 No
ED16D. Aged between 16-24 years old?
[] 1 Yes (Go to next line)
[] 2 No
[] 2 No
ED16E. Has (name) attended an establishment for professionalization formations?
[] 1 Yes (Go to next line)
[] 2 No
[] 2 No
ED16F. Aged between 16-24 years old?
[] 1 Yes (Go to next line)
[] 2 No
[] 2 No
[page 5]
Household Characteristics: HC
HC0A. What was this unit completed?
[] 1 Before April 2008
[] 2 April 2008 or later
[] 2 April 2008 or later
HC0B. In total, including yours, how many households live in this dwelling?
Number of households _ _
HC1C. Type of building where the household lives:
Record the observation.
[] 1 Single family home / villa
[] 2 Apartment (building)
[] 3 Traditional house
[] 4 Precarious habitat
[] 6 Other
[] 2 Apartment (building)
[] 3 Traditional house
[] 4 Precarious habitat
[] 6 Other
HC1D. How many rooms are in your house (not including bathrooms and the kitchen)?
_ _ Number of rooms
HC3. How many rooms do members of this household usually use for sleeping?
_ _ Number of rooms
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.
Natural floor
[] 11 Clay/sand
Finished Floor
[] 31 Wood Wax/parquet
[] 32 Vinyl/asphalt
[] 33 Tiling
[] 34 Cement
[] 35 Carpet
[] 36 Floor Tiles
[] 37 Gerflex
[] 38 Marble
[] 32 Vinyl/asphalt
[] 33 Tiling
[] 34 Cement
[] 35 Carpet
[] 36 Floor Tiles
[] 37 Gerflex
[] 38 Marble
[] 96 Other (specify) ____
[page 6]
HC5. Main material of the roof.
Record observation.
Natural roofing
[] 12 Thatch / Palm Leaf
Rudimentary roofing
[] 23 Wood planks
Finished roofing
[] 33 Calamine/cement fibre
[] 34 Ceramic tiles
[] 35 Cement
[] 34 Ceramic tiles
[] 35 Cement
[] 96 Other (specify) ____
HC6. Main material of the exterior walls.
Record observation.
Natural walls
[] 13 Dirt
[] 14 Toub or dry earth
[] 14 Toub or dry earth
Rudimentary walls
[] 21 Bamboo with mud
[] 22 Stone with mud
[] 22 Stone with mud
Finished Walls
[] 31 Cement
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement Bricks
[] 36 Wood Planks
[] 37 Concrete wall
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement Bricks
[] 36 Wood Planks
[] 37 Concrete wall
[] 96 Other (specify) ____
HC7. Does your household have:
A. A fixed telephone line?
[] 1 Yes
[] 2 No
[] 2 No
B. A radio?
[] 1 Yes
[] 2 No
[] 2 No
C. A living room?
[] 1 Yes
[] 2 No
[] 2 No
D. A dining room?
[] 1 Yes
[] 2 No
[] 2 No
E. A library?
[] 1 Yes
[] 2 No
[] 2 No
F. A water heater (gas)?
[] 1 Yes
[] 2 No
[] 2 No
C. Heat (gas)?
[] 1 Yes
[] 2 No
[] 2 No
HC8. Does your household have electricity?
[] 1 Yes, Interconnected gird
[] 2 Yes, off-grid (generator/isolated system)
[] 3 No (Go to HC10)
[] 2 Yes, off-grid (generator/isolated system)
[] 3 No (Go to HC10)
HC8A. Do you have an electric meter?
[] 1 Yes, individual on behalf of one household member
[] 2 Yes, individual on behalf of a non-member of the household.
[] 3 Yes, individual on behalf of a company or administration
[] 4 Yes, shared by several households
[] No
[] 2 Yes, individual on behalf of a non-member of the household.
[] 3 Yes, individual on behalf of a company or administration
[] 4 Yes, shared by several households
[] No
[page 7]
HC9. Does your household have:
A. A television?
[] 1 Yes
[] 2 No
[] 2 No
B. A refrigerator?
[] 1 Yes
[] 2 No
[] 2 No
C. Freezer
[] 1 Yes
[] 2 No
[] 2 No
D. Laundry Machine
[] 1 Yes
[] 2 No
[] 2 No
E. Dishwasher
[] 1 Yes
[] 2 No
[] 2 No
F. Air conditioner
[] 1 Yes
[] 2 No
[] 2 No
G. Vacuum cleaner
[] 1 Yes
[] 2 No
[] 2 No
H. Satellite receiver with internet (demo)?
[] 1 Yes
[] 2 No
[] 2 No
I. Microwave?
[] 1 Yes
[] 2 No
[] 2 No
J. Hair dryer
[] 1 Yes
[] 2 No
[] 2 No
K. Iron
[] 1 Yes
[] 2 No
[] 2 No
L. Blender
[] 1 Yes
[] 2 No
[] 2 No
M. Printer
[] 1 Yes
[] 2 No
[] 2 No
N. Suppressor
[] 1 Yes
[] 2 No
[] 2 No
O. Intercom
[] 1 Yes
[] 2 No
[] 2 No
P. Oil bath
[] 1 Yes
[] 2 No
[] 2 No
Q. Electric heater
[] 1 Yes
[] 2 No
[] 2 No
HC10. Does any member of your household own:
A. A wristwatch?
[] 1 Yes
[] 2 No
[] 2 No
B. A bicycle?
[] 1 Yes
[] 2 No
[] 2 No
C. A motorcycle or scooter?
[] 1 Yes
[] 2 No
[] 2 No
D. An animal-drawn cart?
[] 1 Yes
[] 2 No
[] 2 No
E. A car, truck or van?
[] 1 Yes
[] 2 No
[] 2 No
F. A boat with a motor?
[] 1 Yes
[] 2 No
[] 2 No
G. Country specific items
(See customization guidelines)
[] 1 Yes
[] 2 No
[] 2 No
HC11. Does any member of your household have a computer or a tablet?
[] 1 Yes
[] 2 No
[] 2 No
HC11A. Does a member of your household have a touchscreen tablet?
[] 1 Yes
[] 2 No
[] 2 No
HC12. Does any member of your household have a mobile telephone?
[] 1 Yes
[] 2 No
[] 2 No
HC12A. Does a member of your household have a smartphone?
[] 1 Yes
[] 2 No
[] 2 No
HC13. Does your household have access to internet at home?
[] 1 Yes
[] 2 No
[] 2 No
HC13A. What is the main type of connection for the internet?
[] 1 DSL Lines
[] 2 4G Modems
[] 3 Fiber Optic
[] 4 Satellite
[] 2 4G Modems
[] 3 Fiber Optic
[] 4 Satellite
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?
[] 1 Yes
[] 2 No
[] 2 No
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.
[] 1 Owner/Co-owner
[] 3 Public Rental
[] 4 Private Rental (Go to HC14B)
[] 5 Free Rental (Go to HC14B)
[] 6 Other (specify) _____ (Go to HC14B)
[] 3 Public Rental
[] 4 Private Rental (Go to HC14B)
[] 5 Free Rental (Go to HC14B)
[] 6 Other (specify) _____ (Go to HC14B)
HC14A. Have you or any member of your household received any state assistance in the provision of this housing? If yes, which one?
[] 1 Public Rental Housing
[] 2 Social/Communal Housing
[] 3 Housing Sold Within the Framework of Rent to Buy
[] 4 Promotional Public Housing (LPP)
[] 5 State Aid Allocated for the Purchase or Construction of a Dwelling
[] 6 Social Land
[] 7 None
[] 2 Social/Communal Housing
[] 3 Housing Sold Within the Framework of Rent to Buy
[] 4 Promotional Public Housing (LPP)
[] 5 State Aid Allocated for the Purchase or Construction of a Dwelling
[] 6 Social Land
[] 7 None
HC14B. Do you or any member of your household own a piece of land for development?
[] 1 Yes
[] 2 No (Go to HC14F)
[] 2 No (Go to HC14F)
HC14C. Are you or any member of your family going to build a home?
[] 1 Yes
[] 2 No (Go to HC14E)
[] 2 No (Go to HC14E)
HC14D. Are you or any member of your household able to receive state assistance for the construction of this housing?
[] 1 Yes
[] 2 No (Go to HC15)
[] 2 No (Go to HC15)
HC14E. Have you or any member of your household applied to the state's specialized services for assistance to construct the house?
[] 1 Yes
[] 2 No
[] 2 No
HC14F. Have you or any member of your household applied to specialized state services for housing?
[] 1 Yes
[] 2 No
[] 2 No
HC15. Does any member of this household own any land that can be used for agriculture?
[] 1 Yes
[] 2 No (Go to HC17)
[] 2 No (Go to HC17)
HC16. How many hectares of agricultural land do members of this household own?
If less than 1, record "00".
_ _ Hectares
[] 95 95 or more
[] 98 DK
[] 95 95 or more
[] 98 DK
HC17. Does this household own any livestock, herds, other farm animals, or poultry?
[] 1 Yes
[] 2 No (Go to HC19)
[] 2 No (Go to HC19)
[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?
Number: _ _
C. Horses, donkeys or mules?
Number: _ _
D. Goats?
Number: _ _
E. Sheep?
Number: _ _
F. Chickens?
Number: _ _
H. Rabbits
Number: _ _
I. Camels
Number: _ _
HC19. Does any member of this household have a bank account?
[] 1 Yes
[] 2 No
[] 2 No
[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)?
A. Program Flat Rate Solidarity Allowance AFS
[] 1 Yes
[] 2 No (Go to B)
[] 2 No (Go to B)
B. Disability Allowance Program
[] 1 Yes
[] 2 No (Go to C)
[] 2 No (Go to C)
C. Social Action Program for School Children (Scholarships, Textbooks, Supplies, Glasses, Cafeterias, Transportation)
[] 1 Yes
[] 2 No (Go to D)
[] 2 No (Go to D)
D. Program Bonus of Schooling (3000 DA)
[] 1 Yes
[] 2 No (Go to E)
[] 2 No (Go to E)
E. Zakat Fund Program
[] 1 Yes
[] 2 No (Go to X)
[] 2 No (Go to X)
X. Any other external assistance programme
[] 1 Yes (specify) ____
[] 2 No (Go to end of module)
[] 2 No (Go to end of module)
ST3. Has your household or anyone in your household received assistance through (name of programme)?
A. [Assistance type 1]
[] 1 Yes (Go to ST4)
[] 2 No (Go to B)
[] 8 DK (Go to B)
[] 2 No (Go to B)
[] 8 DK (Go to B)
B. [Assistance type 2]
[] 1 Yes (Go to ST4)
[] 2 No (Go to C)
[] 8 DK (Go to C)
[] 2 No (Go to C)
[] 8 DK (Go to C)
C. [Assistance type 3]
[] 1 Yes (Go to ST4)
[] 2 No (Go to D)
[] 8 DK (Go to D)
[] 2 No (Go to D)
[] 8 DK (Go to D)
D. Any retirement pension
[] 1 Yes (Go to ST4)
[] 2 No (Go to X)
[] 8 DK (Go to X)
[] 2 No (Go to X)
[] 8 DK (Go to X)
X. Any other external assistance programme
[] 1 Yes (Go to ST4)
[] 2 No (Go to end of module)
[] 8 DK (Go to end of module)
[] 2 No (Go to end of module)
[] 8 DK (Go to end of module)
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.
A. Assistance type 1
[] 1 Months ago _ _ (Go to B)
[] 2 Years ago_ _ (Go to B)
[] 998 DK (Go to B)
[] 2 Years ago_ _ (Go to B)
[] 998 DK (Go to B)
B. Assistance type 2
[] 1 Months ago _ _ (Go to C)
[] 2 Years ago_ _ (Go to C)
[] 998 DK (Go to C)
[] 2 Years ago_ _ (Go to C)
[] 998 DK (Go to C)
C. Assistance type 3
[] 1 Months ago _ _ (Go to D)
[] 2 Years ago_ _ (Go to D)
[] 998 DK (Go to D)
[] 2 Years ago_ _ (Go to D)
[] 998 DK (Go to D)
D. Any retirement pension
[] 1 Months ago _ _ (Go to X)
[] 2 Years ago_ _ (Go to X)
[] 998 DK (Go to X)
[] 2 Years ago_ _ (Go to X)
[] 998 DK (Go to X)
X. Any other external assistance programme
[] 1 Months ago _ _ (Go to end of module)
[] 2 Years ago_ _ (Go to end of module)
[] 998 DK (Go to end of module)
[] 2 Years ago_ _ (Go to end of module)
[] 998 DK (Go to end of module)
[page 10]
Household Energy Use: EU
EU1. In your household, what type of cookstove is mainly used for cooking?
[] 01 Electric stove (Go to EU5)
[] 03 Liquefied petroleum gas (LPG)/cooking gas stove (Go to EU5)
[] 04 Piped natural gas stove (Go to EU5)
[] 06 liquid fuel stove (Go to EU4)
[] 07 manufactured solid fuel stove
[] 08 traditional solid fuel stove
[] 09 three stone stove/open fire (Go to EU4)
[] 96 Other (specify)____ (Go to EU4)
[] 97 No food cooked in household (Go to EU6)
[] 03 Liquefied petroleum gas (LPG)/cooking gas stove (Go to EU5)
[] 04 Piped natural gas stove (Go to EU5)
[] 06 liquid fuel stove (Go to EU4)
[] 07 manufactured solid fuel stove
[] 08 traditional solid fuel stove
[] 09 three stone stove/open fire (Go to EU4)
[] 96 Other (specify)____ (Go to EU4)
[] 97 No food cooked in household (Go to EU6)
EU2. Does it have a chimney?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
EU3. Does it have a fan?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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.
[] 01 Alcohol/ethanol
[] 02 Gasoline/fuel oil
[] 03 Kerosene/paraffin
[] 04 Coal/lignite
[] 05 Charcoal
[] 06 Wood
[] 96 Other (specify) ____
[] 02 Gasoline/fuel oil
[] 03 Kerosene/paraffin
[] 04 Coal/lignite
[] 05 Charcoal
[] 06 Wood
[] 96 Other (specify) ____
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.
In main house
[] 01 No separate room
[] 02 In a separate room
[] 03 In a separate building
[] 02 In a separate room
[] 03 In a separate building
Outdoors
[] 04 Open air
[] 05 On veranda or covered porch
[] 06 Courtyard
[] 07 Garage
[] 08 Basement
[] 05 On veranda or covered porch
[] 06 Courtyard
[] 07 Garage
[] 08 Basement
[] 96 Other (specify) ____
[page 11]
EU6. What does your household mainly use for space heating when needed?
[] 01 Central heating (Go to EU8)
[] 02 manufactured space heater
[] 03 traditional space heater
[] 04 manufactured cookstove
[] 05 traditional cookstove
[] 06 three stone stove/open fire (Go to EU8)
[] 96 Other (specify) (Go to EU8)
[] 97 No space heating in household (Go to EU9)
[] 02 manufactured space heater
[] 03 traditional space heater
[] 04 manufactured cookstove
[] 05 traditional cookstove
[] 06 three stone stove/open fire (Go to EU8)
[] 96 Other (specify) (Go to EU8)
[] 97 No space heating in household (Go to EU9)
EU7. Does it have a chimney?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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.
[] 02 Electricity
[] 03 Piped natural gas
[] 04 Liquefied Petroleum Gas (LPG)/cooking gas
[] 06 Alcohol/ethanol
[] 07 Gasoline/diesel
[] 08 Kerosene/paraffin
[] 09 Coal/lignite
[] 10 Charcoal
[] 11 Wood
[] 96 Other (specify) ____
[] 03 Piped natural gas
[] 04 Liquefied Petroleum Gas (LPG)/cooking gas
[] 06 Alcohol/ethanol
[] 07 Gasoline/diesel
[] 08 Kerosene/paraffin
[] 09 Coal/lignite
[] 10 Charcoal
[] 11 Wood
[] 96 Other (specify) ____
[page 12]
EU9. At night, what does your household mainly use to light the household?
[] 1 Electricity
[] 2 Solar lantern
[] 13 Candle
[] 14 Generator
[] 96 Other (specify) ____
[] 97 No lighting in household
[] 2 Solar lantern
[] 13 Candle
[] 14 Generator
[] 96 Other (specify) ____
[] 97 No lighting in household
[page 13]
Insecticide treated nets: TN
TN1. Does your household have any mosquito nets?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
TN2. How many mosquito nets does your household have?
_ _ Number of nets
TN3. Ask the respondent to show you all the nets in the household. [Up to three nets]
[] 1 Observed
[] 2 Not observed
[] 2 Not observed
TN4. How many months ago did your household get the mosquito net? [Up to three nets]
If less than one month, record "00".
Months ago: _ _
[] 95 More than 36 months ago
[] 98 DK/not sure
[] 95 More than 36 months ago
[] 98 DK/not sure
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.
Long lasting insecticide treated nets (line)
[] 11 Brand A
[] 12 Brand B
[] 13 Brand C
[] 16 Other brand (specify) ____
[] 18 DK brand
[] 12 Brand B
[] 13 Brand C
[] 16 Other brand (specify) ____
[] 18 DK brand
[] 36 Other type (specify) ____
[] 98 DK brand/type
[] 98 DK brand/type
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]
[] 1 Yes, name of campaign
[] 2 Yes, ANC
[] 3 Yes, Immunization
[] 4 No
[] 8 DK
[] 2 Yes, ANC
[] 3 Yes, Immunization
[] 4 No
[] 8 DK
TN11. Check TN10: Is TN10=4 or 8? [Up to three nets]
[] 1 Yes
[] 2 No (Go to TN13)
[] 2 No (Go to TN13)
[page 14]
TN12. Where did you get the net? [Up to three nets]
[] 01 Government health facility
[] 02 Private health facility
[] 03 Pharmacy
[] 04 Shop/market/street
[] 05 Community health worker
[] 06 Religious institution
[] 07 School
[] 96 Other
[] 98 DK
[] 02 Private health facility
[] 03 Pharmacy
[] 04 Shop/market/street
[] 05 Community health worker
[] 06 Religious institution
[] 07 School
[] 96 Other
[] 98 DK
TN13. Did anyone sleep under this mosquito net last night?[Up to three nets]
[] 1 Yes
[] 2 No
[] 8 DK/not sure
[] 2 No
[] 8 DK/not sure
TN14. Check TN13: Did anyone sleep under the net (TN13=1)? [Up to three nets]
[] 1 Yes
[] 2 No (Go to TN16)
[] 2 No (Go to TN16)
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".
____ Name 1
_ _ Line number
_ _ Line number
____ Name 2
_ _ Line number
_ _ Line number
____ Name 3
_ _ Line number
_ _ Line number
____ Name 4
_ _ Line number
_ _ Line number
TN16. Is there another net? [Up to three nets]
[] 1 Yes (Go to next net)
[] 2 No (Go to end of module)
[] 2 No (Go to end of module)
[] Tick here if additional questionnaire used
[page 15]
Water and sanitation: WS
WS0A. Is your household connected to a source of drinkable water?
[] 1 Yes, to the Public Network (AEP)
[] 2 Yes, to a Spring (Go to WS1)
[] 3 Yes, to a Well (Go to WS1)
[] 4 Yes, to a Wadi (Go to WS1)
[] 6 Other (Specify) (Go to WS1)
[] 7 Not Attached (Go to WS1)
[] 2 Yes, to a Spring (Go to WS1)
[] 3 Yes, to a Well (Go to WS1)
[] 4 Yes, to a Wadi (Go to WS1)
[] 6 Other (Specify) (Go to WS1)
[] 7 Not Attached (Go to WS1)
WS0B. Do you have a water meter?
[] 1 Yes Individual on Behalf of a Household Member
[] 2 Yes, Individual Person Who is Not a Member of the Household
[] 3 Yes Individual in the Name of a Company or Administration
[] 4 Yes Shared by Several Households
[] 6 No
[] 7 DK
[] 2 Yes, Individual Person Who is Not a Member of the Household
[] 3 Yes Individual in the Name of a Company or Administration
[] 4 Yes Shared by Several Households
[] 6 No
[] 7 DK
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).
Piped water
[] 11 Piped into dwelling (Go to WS7)
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour (Go to WS3)
[] 14 Public tap/standpipe (Go to WS3)
[] 21 Tube well/borehole (Go to WS3)
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour (Go to WS3)
[] 14 Public tap/standpipe (Go to WS3)
[] 21 Tube well/borehole (Go to WS3)
Dug well
[] 31 Protected well (Go to WS3)
[] 32 Unprotected well (Go to WS3)
[] 32 Unprotected well (Go to WS3)
Spring
[] 41 Protected spring (Go to WS3)
[] 42 Unprotected spring (Go to WS3)
[] 51 Rainwater (Go to WS3)
[] 61 Tanker-truck (Go to WS4)
[] 71 Cart with small tank (Go to WS4)
[] 81 Surface water (river, dam, lake, pond, stream, canal, irrigation channel) (Go to WS3)
[] 42 Unprotected spring (Go to WS3)
[] 51 Rainwater (Go to WS3)
[] 61 Tanker-truck (Go to WS4)
[] 71 Cart with small tank (Go to WS4)
[] 81 Surface water (river, dam, lake, pond, stream, canal, irrigation channel) (Go to WS3)
Packaged water
[] 91 Bottled water
[] 96 Other (specify) ____ (Go to WS3)
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.
Piped water
[] 11 Piped into dwelling (Go to WS7)
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour
[] 14 Public tap/standpipe
[] 21 Tube well/borehole
[] 12 Piped into yard/plot (Go to WS7)
[] 13 Piped into neighbour
[] 14 Public tap/standpipe
[] 21 Tube well/borehole
Dug well
[] 31 Protected well
[] 32 Unprotected well
[] 32 Unprotected well
Spring
[] 41 Protected spring
[] 42 Unprotected spring
[] 51 Rainwater
[] 61 Tanker-truck (Go to WS4)
[] 71 Cart with small tank (Go to WS4)
[] 72 Water kiosk (Go to WS4)
[] 81 Surface water (river, dam, lake, pond, stream, canal, irrigation channel)
[] 42 Unprotected spring
[] 51 Rainwater
[] 61 Tanker-truck (Go to WS4)
[] 71 Cart with small tank (Go to WS4)
[] 72 Water kiosk (Go to WS4)
[] 81 Surface water (river, dam, lake, pond, stream, canal, irrigation channel)
[] 96 Other (specify) ____
[page 16]
WS3. Where is that water source located?
[] 1 In own dwelling (Go to WS7)
[] 2 In own yard/plot (Go to WS7)
[] 3 Elsewhere
[] 2 In own yard/plot (Go to WS7)
[] 3 Elsewhere
WS4. How long does it take for members of your household to go there, get water, and come back?
[] 000 Members do not collect (go to WS7)
_ _ _Number of minutes
[] 998 DK
_ _ _Number of minutes
[] 998 DK
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.
Name: ____
Line number: _ _
Line number: _ _
WS6. Since last (day of the week), how many times has this person collected water?
Number of times: _ _
[] 98 DK
[] 98 DK
WS7. In the last month, has there been any time when your household did not have sufficient quantities of drinking water?
[] 1 Yes, at least once
[] 2 No, always sufficient (Go to WS9)
[] 8 DK (Go to WS9)
[] 2 No, always sufficient (Go to WS9)
[] 8 DK (Go to WS9)
WS8. What was the main reason that you were unable to access water in sufficient quantities when needed?
[] 1 Water not available from source
[] 2 Water too expensive
[] 3 Source not accessible
[] 6 Other (specify) ____
[] 8 DK
[] 2 Water too expensive
[] 3 Source not accessible
[] 6 Other (specify) ____
[] 8 DK
WS9. Do you or any other member of this household do anything to the water to make it safer to drink?
[] 1 Yes
[] 2 No (Go to WS11)
[] 8 DK (Go to WS11)
[] 2 No (Go to WS11)
[] 8 DK (Go to WS11)
[page 17]
WS10. What do you usually do to make the water safer to drink?
Probe: Anything else?
Record all methods mentioned.
[] A Boil
[] B Add bleach/chlorine
[] C Strain it through a cloth
[] D Use water filter (ceramic, sand, composite, ect)
[] E Solar disinfection
[] F Let it stand and settle
[] X Other (specify) ____
[] Z DK
[] B Add bleach/chlorine
[] C Strain it through a cloth
[] D Use water filter (ceramic, sand, composite, ect)
[] E Solar disinfection
[] F Let it stand and settle
[] X Other (specify) ____
[] Z DK
WS10A. What type of tank do you use to store/hold water? Record all types of tanks used by the household.
[] A Water Tank
[] B Galvanized Tank
[] C Plastic Tank
[] D Plastic Water Tank
[] E Plastic Water Jerrycans
[] F Jerrycans, Drums that Have Contained Chemical/toxic Products
[] X Other (specify)
[] DK
[] B Galvanized Tank
[] C Plastic Tank
[] D Plastic Water Tank
[] E Plastic Water Jerrycans
[] F Jerrycans, Drums that Have Contained Chemical/toxic Products
[] X Other (specify)
[] DK
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.
Flush/pour flush
[] 11 Flush to piped sewer system (go to WS14)
[] 12 Flush to septic tank
[] 13 Flush to pit latrine
[] 14 Flush to open drain (go to WS14)
[] 15 Connected to a Wadi (go to WS14)
[] 16 Connected to Something Else (go to WS14)
[] 18 Flush to DK where (go to WS14)
[] 12 Flush to septic tank
[] 13 Flush to pit latrine
[] 14 Flush to open drain (go to WS14)
[] 15 Connected to a Wadi (go to WS14)
[] 16 Connected to Something Else (go to WS14)
[] 18 Flush to DK where (go to WS14)
Pit latrine
[] 21 Ventilated improved pit latrine
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 31 Composting toilet
[] 41 Bucket (Go to WS14)
[] 51 Hanging toilet, hanging latrine (Go to WS14)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 31 Composting toilet
[] 41 Bucket (Go to WS14)
[] 51 Hanging toilet, hanging latrine (Go to WS14)
[] 95 No facility/bush/field (Go to next module)
[] 96 Other (specify) ____ (Go to WS14)
[] 96 Other (specify) ____ (Go to WS14)
WS12. Has your (answer from WS11) ever been emptied?
[] 1 Yes, emptied, within the last 5 years
[] 2 Yes, emptied, more than 5 years ago
[] 3 Yes, emptied, don't know when
[] 4 No, never emptied (Go to WS14)
[] 5 Buried, changed places
[] 8 DK (Go to WS14)
[] 2 Yes, emptied, more than 5 years ago
[] 3 Yes, emptied, don't know when
[] 4 No, never emptied (Go to WS14)
[] 5 Buried, changed places
[] 8 DK (Go to WS14)
WS13. The last time it was emptied, where were the contents emptied to?
Probe: Was it removed by a service provider?
Removed by service provider
[] 1 To a treatment plant
[] 2 Buried in a covered pit
[] 3 To don't know where
[] 2 Buried in a covered pit
[] 3 To don't know where
Emptied by household
[] 4 Buried in a covered pit
[] 5 To uncovered pit, open ground, water body or elsewhere
[] 6 Other (specify) ____
[] 8 DK
[] 5 To uncovered pit, open ground, water body or elsewhere
[] 6 Other (specify) ____
[] 8 DK
[page 18]
WS14. Where is this toilet facility located?
[] 1 In own dwelling
[] 2 In own yard/plot
[] 3 Elsewhere
[] 2 In own yard/plot
[] 3 Elsewhere
WS15. Do you share this facility with others who are not members of your household?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
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?
[] 1 Shared with known households (not public)
[] 2 Shared with general public (Go to next module)
[] 2 Shared with general public (Go to next module)
WS17. How many households in total use this toilet facility, including your own household?
0 _ Number of households (if less than 10)
[] 10 Ten or more households
[] 98 DK
[] 10 Ten or more households
[] 98 DK
[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.
Observed
[] 1 Fixed facility observed (sink/tap) in dwelling
[] 2 Fixed facility observed (sink/tap) in yard /plot
[] 3 Mobile object observed (bucket/jug/kettle)
[] 2 Fixed facility observed (sink/tap) in yard /plot
[] 3 Mobile object observed (bucket/jug/kettle)
Not observed
[] 4 No handwashing place in dwelling/yard/plot (Go to HW5)
[] 5 No permission to see (Go to HW4)
[] 5 No permission to see (Go to HW4)
[] 6 Other reason (specify) ____(Go to HW5)
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.
[] 1 Water is available
[] 2 Water is not available
[] 2 Water is not available
HW3. Is soap or detergent or ash/mud/sand present at the place for handwashing?
[] 1 Yes, present (Go to HW7)
[] 2 No, not present (Go to HW5)
[] 2 No, not present (Go to HW5)
HW4. Where do you or other members of your household most often wash your hands?
Fixed facility (sink/tap)
[] 1 In dwelling
[] 2 In yard/plot
[] 2 In yard/plot
[] 3 Mobile object (bucket/jug/kettle)
[] 4 No handwashing place in dwelling/yard/plot
[] 6 Other (specify) ____
[] 4 No handwashing place in dwelling/yard/plot
[] 6 Other (specify) ____
HW5. Do you have any soap or detergent or ash/mud/sand in your house for washing hands?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
HW6. Can you please show it to me?
[] 1 Yes, shown
[] 2 No, not shown (Go to next module)
[] 2 No, not shown (Go to next module)
HW7. Record your observation.
Record all that apply.
[] A Bar or liquid soap
[] B Detergent (powder/liquid/paste)
[] C Ash/mud/sand
[] B Detergent (powder/liquid/paste)
[] C Ash/mud/sand
[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.
Salt tested
[] 1 0 PPM (no reaction)
[] 2 Below 15 PPM (between 0 PPM and 15 PPM) (Go to HH13)
[] 3 Above 15 PPM (at least 15 PPM) (Go to HH13)
[] 2 Below 15 PPM (between 0 PPM and 15 PPM) (Go to HH13)
[] 3 Above 15 PPM (at least 15 PPM) (Go to HH13)
Salt not tested
[] 4 No salt in the house (Go to HH13)
[] 6 Other reason (specify) ____ (Go to HH13)
[] 6 Other reason (specify) ____ (Go to HH13)
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.
Salt tested
[] 1 0 PPM (no reaction)
[] 2 Below 15 PPM (between 0 and 15 PPM)
[] 3 Above 15 PPM (at least 15 PPM)
[] 2 Below 15 PPM (between 0 and 15 PPM)
[] 3 Above 15 PPM (at least 15 PPM)
Salt not tested
[] 6 Other reason (specify) ____
SA2A. Do you buy salt when shopping?
[] 1 Yes
[] 2 No
[] 2 No
HH13. Record the time.
Hours and minutes: _ _:_ _
HH14. Language of the Questionnaire.
[] 1 English
[] 2 Language 2
[] 3 Language 3
[] 2 Language 2
[] 3 Language 3
HH15. Language of the Interview.
[] 1 English
[] 2 Language 2
[] 3 Language 3
[] 6 Other language (specify) ____
[] 2 Language 2
[] 3 Language 3
[] 6 Other language (specify) ____
HH16. Native language of the Respondent.
[] 1 English
[] 2 Language 2
[] 3 Language 3
[] 6 Other language (specify) ____
[] 2 Language 2
[] 3 Language 3
[] 6 Other language (specify) ____
HH17. Was a translator used for any parts of this questionnaire?
[] 1 Yes, entire questionnaire
[] 2 Yes, part of questionnaire
[] 3 No, not used
[] 2 Yes, part of questionnaire
[] 3 No, not used
HH18. Check HL6 in the "List of household members" and indicate the total number of children age 5-17 years:
[] 0 No children (Go to HH29)
[] 1 1 child (Go to HH27)
2 or more children (number): _
[] 1 1 child (Go to HH27)
2 or more children (number): _
[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
[] 1 Male
[] 2 Female
[] 2 Female
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.
Last digit of household number (from HH2): _
Total number of eligible children in the household (from HH18): _
Total number of eligible children in the household (from HH18): _
HH26. Record the rank number (HH20), line number (HH21), name (HH22) and age (HH24) of the selected child.
Rank number: _
Line number: _ _
Name: ____
Age: _ _
Line number: _ _
Name: ____
Age: _ _
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.
Rank Number: _
Line Number: _ _
Name: ____
Age: _ _
Line Number: _ _
Name: ____
Age: _ _
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?
[] 1 Yes, at least one woman age 15-49
[] 2 No (Go to HH34)
[] 2 No (Go to HH34)
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?
[] 1 Yes, at least one girl age 15-17
[] 2 No (Go to HH34)
[] 2 No (Go to HH34)
HH32. Check HL20 in the list of household members: Is consent required for interviewing at least one girl age 15-17?
[] 1 Yes, at least one girl age 15-17 with HL20 does not equal 90
[] 2 No, HL20 does not equal 90 for all girls age 15-17 (Go to HH34)
[] 2 No, HL20 does not equal 90 for all girls age 15-17 (Go to HH34)
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?
[] "Yes" for all girls age 15-17. Continue with HH34.
[] "No" for at least one girl age 15-17 and "Yes" to at least one girl age 15-17. Record "06" in WM17 (also in UF17 and FS17, if applicable) on individual questionnaires for those adult consent was not given. Then continue with HH34.
[] "No" for all girls age 15-17. Record "06" in WM17 (also in UF17 and FS17, if applicable) on all individual questionnaires for whom adult consent was not given. Then continue with HH34.
[] "No" for at least one girl age 15-17 and "Yes" to at least one girl age 15-17. Record "06" in WM17 (also in UF17 and FS17, if applicable) on individual questionnaires for those adult consent was not given. Then continue with HH34.
[] "No" for all girls age 15-17. Record "06" in WM17 (also in UF17 and FS17, if applicable) on all individual questionnaires for whom adult consent was not given. Then continue with HH34.
HH40. Check HL10 in the "List of household members": Are there any children age 0-4?
[] 1 Yes, at least one
[] 2 No (Go to HH42)
[] 2 No (Go to HH42)
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?
[] Yes HH9=1
[] No HH9=2 (Go to HH45)
[] No HH9=2 (Go to HH45)
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.
[] 1 Yes permission is given
[] 2 No, permission is not given (Record 02 in WQ31 on the water quality testing questionnaire)
[] 2 No, permission is not given (Record 02 in WQ31 on the water quality testing questionnaire)
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
01-14
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.
Name ____ Age ____
AE3. 15 years or older?
[] 1 Yes
[] 2 No (Next line)
[] 2 No (Next line)
AE4. What is the job situation of (name) during the 30 days preceding the date of the interview?
[] 1 Employed
[] 2 Student/scholar/professional in Training (Go to AE9)
[] 3 Looking for work (Go to AE10)
[] 4 Retired (Go to AE12)
[] 5 Another type of inactive work (Go to AE11)
[] 2 Student/scholar/professional in Training (Go to AE9)
[] 3 Looking for work (Go to AE10)
[] 4 Retired (Go to AE12)
[] 5 Another type of inactive work (Go to AE11)
AE5. What is (name)?s financial situation in this profession?
[] 1 Salaried
[] 2 Not Salaried (Go to AE7S)
[] 2 Not Salaried (Go to AE7S)
AE6. Does (name) work in the public or private sector?
[] 1 Public (Go to AE8)
[] 2 Private
[] 2 Private
AE7. Is (name) affiliated with a social insurance fund? Including: CNAS, CASNOS, CAMSSP.
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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.
[] 0 No
[] 1 DAIP (ANEM)
[] 2 DAIS (ADS)
[] 3 ANSEJ
[] 4 CNAC
[] 5 ANGEM
[] 8 DK
[] 1 DAIP (ANEM)
[] 2 DAIS (ADS)
[] 3 ANSEJ
[] 4 CNAC
[] 5 ANGEM
[] 8 DK
AE9. Is (name) on scholarship?
[] 1 Yes (Go to AE12)
[] 2 No (Go to AE12)
[] 8 DK (Go to AE12)
[] 2 No (Go to AE12)
[] 8 DK (Go to AE12)
AE10. Has (name) registered with the ANEM?
[] 1 Yes (Go to AE12)
[] 2 No (Go to AE12)
[] 8 DK (Go to AE12)
[] 2 No (Go to AE12)
[] 8 DK (Go to AE12)
AE11. Does (name) receive assistance from the state?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
AE12. Does (name) have a chiffa card ?
[] 1 Yes, individual
[] 2 Yes, entitled
[] 3 No
[] 8 DK
[] 2 Yes, entitled
[] 3 No
[] 8 DK
Household Waste
DM1. Where do you keep the waste (bags, garbage cans, etc)?
[] 1 In the house inside the kitchen
[] 2 In the house outside of the kitchen
[] 3 In the yard/garden/plot
[] 4 Elsewhere
[] 6 Other (specify)
[] 2 In the house outside of the kitchen
[] 3 In the yard/garden/plot
[] 4 Elsewhere
[] 6 Other (specify)
DM2. How often do you dispose of household waste?
[] 1 Each day
[] 2 At least twice a week
[] 3 Once a week
[] 6 Other (specify)
[] 2 At least twice a week
[] 3 Once a week
[] 6 Other (specify)
DM3. How do you dispose of household waste?
[] 1 Garbage collector
[] 2 Deposited in a special place
[] 3 Burned
[] 4 Thrown in the street
[] 6 Other (specify)
[] 2 Deposited in a special place
[] 3 Burned
[] 4 Thrown in the street
[] 6 Other (specify)
DM4. What do you do with unused medications that are past their expiration date and that are not yet expired?
[] 1 Kept to be used
[] 2 Give to pharmacies
[] 3 Give to a health structure
[] 4 Give to an association
[] 5 Give to members of the family/neighbors
[] 6 Sort and dispose of separately from other waste
[] 7 Thrown away with other waste
[] 8 Never has used any medication
[] 96 Other (specify)
[] 2 Give to pharmacies
[] 3 Give to a health structure
[] 4 Give to an association
[] 5 Give to members of the family/neighbors
[] 6 Sort and dispose of separately from other waste
[] 7 Thrown away with other waste
[] 8 Never has used any medication
[] 96 Other (specify)
DM5. How do you dispose of unused/expired medications?
[] 1 Give to pharmacies
[] 2 Deliver to a health care facility
[] 3 Sort and dispose of separately from other waste
[] 4 Throw in with other waste
[] 5 Never used any medication
[] 6 Other (specify)
[] 2 Deliver to a health care facility
[] 3 Sort and dispose of separately from other waste
[] 4 Throw in with other waste
[] 5 Never used any medication
[] 6 Other (specify)
DM6. What do you do with used syringes and needles (insulin syringes, etc.)?
[] 1 Give to pharmacies
[] 2 Deliver to a health care facility
[] 3 Sort and dispose of separately from other waste
[] 4 Throw in with other waste
[] 5 Never used syringes
[] 6 Other (specify)
[] 2 Deliver to a health care facility
[] 3 Sort and dispose of separately from other waste
[] 4 Throw in with other waste
[] 5 Never used syringes
[] 6 Other (specify)
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.
[] A Clean and dry area
[] B Dirty area (garbage dump)
[] C Stagnant water
[] D Flooded area
[] X Other (specify)
[] B Dirty area (garbage dump)
[] C Stagnant water
[] D Flooded area
[] X Other (specify)
Chronic Diseases (People Aged 15 Years and Over)
MC1. Number of line.
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
Name ____
Age _ _ _
Age _ _ _
MC3. 15 years of age or older?
[] 1. Yes
[] 2. No (Next Line)
[] 2. No (Next Line)
MC4. Does (name) have a chronic illness?
[] 1. Yes
[] 2. No (Next Line)
[] 8. DK (Next Line)
[] 2. No (Next Line)
[] 8. DK (Next Line)
MC5. What illness does he/she have?
[] 1. Arterial hypertension
[] 2. Diabetes
[] 3. Cardiovascular disease
[] 4. Respiratory diseases
[] 5. Joint disease
[] 6. Cancer (all types)
[] 7. Neuropsychiatric disorders
[] 8. Renal insufficiency
[] 9. Hereditary diseases (hemophilia, thalassemia, celiac...)
[] 96. Other (specify)
[] 2. Diabetes
[] 3. Cardiovascular disease
[] 4. Respiratory diseases
[] 5. Joint disease
[] 6. Cancer (all types)
[] 7. Neuropsychiatric disorders
[] 8. Renal insufficiency
[] 9. Hereditary diseases (hemophilia, thalassemia, celiac...)
[] 96. Other (specify)
MC6. Has this disease been diagnosed by a doctor?
[] 1. Yes
[] 2. No (Go to MC8)
[] 8. DK (Go to MC8)
[] 2. No (Go to MC8)
[] 8. DK (Go to MC8)
MC7. What age was (name) when this disease was diagnosed by the doctor?
Age _ _
MC8. Does (name) follow a treatment for this illness?
[] 1. Yes
[] 2. No
[] 2. No
MC9. Does (name) have a second chronic illness?
[] 1. Yes
[] 2. No (Go to MC13)
[] 8. DK (Go to MC13)
[] 2. No (Go to MC13)
[] 8. DK (Go to MC13)
MC10. What illness does he/she have?
[] 1. Arterial hypertension
[] 2. Diabetes
[] 3. Cardiovascular disease
[] 4. Respiratory diseases
[] 5. Joint disease
[] 6. Cancer (all types)
[] 7. Neuropsychiatric disorders
[] 8. Renal insufficiency
[] 9. Hereditary diseases (hemophilia, thalassemia, celiac...)
[] 96. Other (specify)
[] 2. Diabetes
[] 3. Cardiovascular disease
[] 4. Respiratory diseases
[] 5. Joint disease
[] 6. Cancer (all types)
[] 7. Neuropsychiatric disorders
[] 8. Renal insufficiency
[] 9. Hereditary diseases (hemophilia, thalassemia, celiac...)
[] 96. Other (specify)
MC11. Has this disease been diagnosed by a doctor?
[] 1. Yes
[] 2. No
[] 8. DK
[] 2. No
[] 8. DK
MC12. Does (name) follow a treatment for this illness?
[] 1. Yes
[] 2. No
[] 2. No
MC13. Does (name) use a Chiffa card for this chronic illness?
[] 1. Yes
[] 2. No
[] 8. DK
[] 2. No
[] 8. DK
General Mortality
MG1. During the past 5 years i.e. since January 2013, has there been a member of this household who has died?
[] 1. Yes
[] 2. No (End)
[] 2. No (End)
MG2. How many members have died since January 2013?
Number of Deaths _ _ _
MG3. No. of order:
Order _ _ _ _
MG4. Can you give me the name(s) and surname(s) of the member(s) (see MG2) who died?
Name and Surname _______
MG5. What is the relationship of (name) to the (current) head of household?
Kinship _______
MG6. (Name) is male or female?
[] 1. Male
[] 2. Female
[] 2. Female
MG7. What is the date of birth of (name)?
Day _ _
Month _ _
Year _ _ _ _
[] 98. Days DK
[] 98. Months DK
[] 9998. Year DK
Month _ _
Year _ _ _ _
[] 98. Days DK
[] 98. Months DK
[] 9998. Year DK
MG8. What is the date of death of (name)?
Day _ _
Month _ _
Year _ _ _ _
[] 98. Days DK
[] 98. Months DK
[] 9998. Year DK
Month _ _
Year _ _ _ _
[] 98. Days DK
[] 98. Months DK
[] 9998. Year DK
MG9. Where did (name) die?
[] 1. Hospital setting
[] 2. Home
[] 3. Other
[] 2. Home
[] 3. Other
MG10. Was the death of (name) registered at the civil registry office?
[] 1. Yes, within the time limit
[] 2. Yes, by judgment
[] 3. No[] 8. DK
[] 2. Yes, by judgment
[] 3. No[] 8. DK