We are from (Bureau of Statistics). We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will take about (20) minutes. All the information we obtain will remain strictly confidential and your answers will never be identified. During this time I would like to speak with the household head and all mothers or others who take care of children in the household.
May I start now? If permission is given, begin the interview.

Household Information Panel: HH

HH1A. Region number:_ _ _

HH1. ED/Cluster number: _ _ _

HH2A. Building number: _ _ _

HH2. Household Number _ _ _

HH2V. Ward/Village/Community name and number: _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

HH5. Day/month/year of interview _ _ / _ _ / _ _ _ _

HH6. Area:

Household Interview Duration
Visit 1 2
HH8s. Start time____

HH8. End time ____

HH8. Name of head of household: ____

Fill in the region, ED/cluster, and household numbers at the top of each page of this questionnaire. After all questionnaires for the household have been completed, fill in the following information:

HH9. Result of HH interview:

HH10. Respondent to HH questionnaire

HH11. Total number of household members: _ _

HH12. No. of women eligible for interview: _ _

HH13. No. of women questionnaires completed: _ _

HH14. No. of children under age 5: _ _

HH15. No. of under-5 questionnaires completed: _ _

Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as call-back times, incomplete individual interview forms, number of attempts to re-visit, etc.

HH16. Data entry clerk: _ _Name and No.

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? (These may include children in school or at work). If yes, complete listing.
Then, ask questions starting with hl5 for each person at a time. Add a continuation sheet if there are more than 15 household members.
[] Tick here if continuation sheet used

HL1. Line no.: _ _

HL2. Name: ____

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

HL4. Is (name) male or female?

HL5. How old was (name) in his/her last birthday?
Record in Completed years
HL6. Eligible for women's interview

HL7. Eligible for child labour module
For each child age 5-14: Who is the mother or primary caretaker of this child?

HL8. Eligible for under-5 interview
For each child under 5: Who is the mother or primary caretaker of this child

HL8A. If age 18-59 years.

For children age 0-17 years ask HL9-HL12

HL9. Is (name's) natural mother alive?

HL10. If alive: Does (name's) natural mother live in this household?

HL10A. If mother does not live in household: Has (name's) mother been very sick for at least 3 months in the past 12 months?

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

HL12. If alive: Does (name's) natural father live in this household?

Are there any other persons living here - even if they are not members of your family or do not have parents living in this household?
Including children at work or at school? If yes, insert child's name and complete form.
Then, complete the totals below.

Totals

Now for each woman age 15-49 years, write her name and line number and other identifying information in the information panel of the 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 the questionnaire for children under five.
You should now have a separate questionnaire for each eligible woman and each child under five in the household.

Education Module: ED

For household members age 5 and above

ED1. Line no. _ _

ED1A. Name ____

ED2. Has (name) ever attended school or preschool?

ED3. What is the highest level of school (name) attended? What is the highest grade (name) completed at this level?

For household members age 5-24 years

ED4. During this school year, did (name) attend school or preschool at any time?

ED5. Since last (day of the week), how many days did (name) attend school?

ED6. During this school year, which level and grade is/was (name) attending?

ED7. Did (name) attend school or preschool at any time during the previous school year, that is (2004-2005)?

ED8. During that previous school year, which level and grade did (name) attend?

Water and sanitation module: WS

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

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

WS3. How long does it take to go there, get water, and come back?

WS4. Who usually goes to this source to fetch the water for your household?
Probe: Is this person under age 15? What sex?
Circle code that best describes this person.

WS5. Do you treat your water in any way to make it safer to drink?

WS7. 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.

WS8. Does any other households use this toilet facility?

WS9. How many households in total use this toilet facility

Household characteristics module: HC

HC2. How many rooms in this household are used for sleeping? (see explanation in manual)

HC3. What is the main material of the dwelling floor?

HC4. What is the main material used for roofing?

HC5. Main material of the walls.
Record observation.
HC8. Is the cooking usually done in the house, in a separate building, or outdoors?

HC9. Does your household have:











HC10. Does any member of your household own:







ITN Module: TN

TN1. Does your household have any mosquito nets that can be used while sleeping?

TN2. How many mosquito nets does your household have? If 7 or more nets, record '7'.

TN5. When you got the (most recent) net, was it already treated with an insecticide to kill or keep away mosquitos?

TN6. How many months ago was the (most recent) net obtained?
If less than 1 month ago, record '00'. If answer is "12 months" or "1 year", probe to determine if net was treated exactly 12 months ago or earlier or later.

TN8. How long ago was the most recent soaking/dipping done?
If less than 1 month ago, record '00'. If answer is "12 months" or "1 year", probe to determine if net was treated exactly 12 months ago or earlier or later.

Children orphaned and made vulnerable by HIV/AIDS


OV1. Check HL5: any children 0-17?

OV2. I would like you to think back over the past months. Has any usual member of your household dies in the last 12 months?

OV3. (Of those who dies in the past 12 months) were any of these people between the ages of 18 and 59?

OV4. (Of those who died in the past 12 months and were between the ages of 18 and 59) were any of these people seriously ill for 3 of the 12 months before he/she dies?

OV5. Return to the household listing and check the following:
Check totals for HL9 and HL11.

Check totals for HL8A.

Check totals for HL10A and HL12A.

OV8. List all children aged 0-17 below. Record names, line numbers and ages of all children, beginning with the first child and continue in order in which listed in the Household (Extended) Listing Module. Use a continuation sheet if there are more than 4 children age 0-17 in the household. Tick here if continuation sheet used. Ask all questions for one child before moving to the next child.

OV9. I would like to ask you about any formal, organized help or support that your household may have received for (name) and for which you did not have to pay. By formal organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community-based. Remember this should be support for which you did not pay.

OV10. Now I would like to ask you about the support your household received for (name). In the last 12 months, has your household received any medical support for (name), such as medical care, supplies or medicine?

OV11. In the last 12 months, has your household received any emotional or psychological support for (name), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home?

OV12. Did your household receive any of this support in the past 3 months?

OV13. In the last 12 months, has your household received any material support for (name), such as clothing, food or financial support?

OV14. Did your household receive any of this support in the past 3 months?

OV15. In the last 12 months, has your household received any social support for (name), such as help in household work, training for a caregiver, or legal services?

OV16. Did your household receive any of this support in the past 3 months?

OV17. Check OV8 for age of child:

OV18. In the last 12 months, has your household received any support for (name's) schooling, such as allowance, free admission, books or supplies?

Child labour module: CL

To be administered to mother/caretaker of each child in the household age 5 through 14 years. For household members below age 5 or above age 14, leave rows blank.
Now I would like to ask about any work children in this household may do.

CL1. Line no. _ _

CL2. Name: ____

CL3. Since last (day of the week), did (name) do any kind of work for someone. who is not a member of this household?
If yes: For pay in cash or kind?

CL4. If yes: About how many hours during that week did he/she do this work for someone who is not a member of this household?

CL5. At any time during the past year, did (name) do any kind of work for someone who is not a member of this household?
If yes: For pay in cash or kind?

CL6. During the past week, did (name) help with household chores such as shopping, collecting firewood, cleaning, fetching water, or caring for children?

CL7. If yes: Since last (day of the week), about how many hours did he/she spend doing these chores? _ _

CL8. During the past week, did (name) do any other family work (on the farm or in a business or selling goods in the street)

CL9. If yes: Since last (day of the week), about how many hours did he/she do this work? _ _

Child discipline module: CD

Table 1: Children aged 2-14 years eligible for child discipline questions
Review the household listing and list each of the children aged 2-14 years below in order according to their line number (HL1). Do not include other household members outside of the age range 2-14 years. Record the line number, name, sex, age, and the line number of the mother or caretaker for each child. Then record the total number of children aged 2-14 in the box provided (CD7).

CD1. Rank no.

CD2. Line no. from HL1.

CD3. Name from HL2.

CD4. Sex from HL4.

CD5. Age from HL5.

CD6. Line no. of mother/caretaker from HL7 or HL8.

CD7. Total children aged 2-14 years _ _

If there is only one child age 2-14 years in the household, then skip table 2 and go to CD9; write down the rank number of the child and continue with CD11

Table 2: Selection of random child for child discipline questions
Use this table to select one child between the ages of 2 and 14 years, if there is more than one child in that age range in the household. Look for the last digit of the household number 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 CD7 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 about whom the questions will be asked. Record the rank number in CD9 below. Finally, record the line number and name of the selected child in CD11 on the next page. Then, find the mother or primary caretaker of that child, and ask the questions, beginning with CD12.

CD8. Last digit of the questionnaire number 0-9
Total number of eligible children in the household 1-8+
[Table omitted]

CD9. Record the rank number of the selected child

Identify eligible child aged 2 to 14 in the household using the tables on the preceding page, according to your instructions. Ask to interview the mother or primary caretaker of the selected child (identified by the line number in CD6).

CD11. Write name and line no. of the child selected for the module from CD3 and CD2, based on the rank number in CD9.

CD12. All 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. I.E. Since (day of interview) of last month. At any time during that period, when (name) behaved 'bad', did you or anyone else in your household:

CD12A. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

CD12B. Explained why something (the behavior) was wrong.

CD12C. Shook him/her.

CD12D. Shouted, hollered on or screamed at him/her.

CD12E. Gave him/her something else to do as a distraction.

CD12F. Spanked, hit or slapped him/her on the bottom with bare hand.

CD12G. Lash or hit him/her on the bottom and or other parts on the body with something like a stick, wood, belt, hairbrush or other hard object.

CD12H. Called him/her stupid, good for nothing, dumb, lazy, or another name like that.

CD12I. Hit or slapped him/her on the face, head or ears with bare hand.

CD12J. Hit or slapped him/her on the Face, head or ears with bare hand.

CD12K. Beat him/her up with. Something (an object) over and over as hard as one could.

CD13. Do you believe that in order to raise or bring up (name) properly, you need to physically punish him/her by beating or lashing or hitting or such like?

CD14. Check household listing, column HL6. You should have a questionnaire with the information panel filled in for each eligible woman.

CD15. Does any child under the age of 5 reside in the household?
Check household listing, column HL8. You should have a questionnaire with the information panel filled in for each eligible child.