MICS Household Questionnaire
Multiple Indicator Cluster Survey
Household Information Panel: HH
HH1. Cluster number: _ _ _
HH2. Household number: _ _
HH3. Interviewer's name and number
Name ____
Number _ _ _
Number _ _ _
HH4. Supervisor's name and number:
Name ____
Number _ _ _
Number _ _ _
HH5. Day/month/year of interview
_ _ / _ _ /2015
HH6. Area
[] 1. Urban
[] 2. Rural
[] 2. Rural
HH7. Region
[] 1. Akmola
[] 2. Aktobe
[] 3. Almaty oblast
[] 4. Atyrau
[] 5. West Kazakhstan
[] 6. Zhambyl
[] 7. Karaganda
[] 8. Kostanai
[] 9. Kyzylorda
[] 10. Mangistau
[] 11. South Kasakhstan
[] 12. Pavlodar
[] 13. North Kazakhstan
[] 14. East Kazakhstan
[] 15. Astana city
[] 16. Almaty city
[] 2. Aktobe
[] 3. Almaty oblast
[] 4. Atyrau
[] 5. West Kazakhstan
[] 6. Zhambyl
[] 7. Karaganda
[] 8. Kostanai
[] 9. Kyzylorda
[] 10. Mangistau
[] 11. South Kasakhstan
[] 12. Pavlodar
[] 13. North Kazakhstan
[] 14. East Kazakhstan
[] 15. Astana city
[] 16. Almaty city
We are from the Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan. We are conducting a survey about the situation of children, families and households. I would like to talk to you about these subjects. The interview will take about 25 minutes. All the information we obtain will remain strictly confidential and anonymous. May I start now?
[] Yes, permission is given (Go to HH18 to record the time and then begin the interview.)
[] No, permission is not given (Circle 04 in HH9. Discuss this result with your supervisor.)
[] No, permission is not given (Circle 04 in HH9. Discuss this result with your supervisor.)
HH9. Result of household interview:
[] 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/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/address not a dwelling
[] 06. Dwelling destroyed
[] 07. Dwelling not found
[] 96. Other (specify) ____
After the household questionnaire has been completed, fill in the following information:
HH10. Respondent to household questionnaire:
Name: ____ _ _
After the household questionnaire has been completed, fill in the following information:
HH11. Total number of household members: _ _
After the household questionnaire has been completed, fill in the following information:
HH12. Number of women age 15-49 years: _ _
After all questionnaires for the household have been completed, fill in the following information:
HH13. Number of women's questionnaires completed: _ _
After the household questionnaire has been completed, fill in the following information:
HH14. Number of children under age 5: _ _
After all questionnaires for the household have been completed, fill in the following information:
HH15. Number of under-5 questionnaires completed: _ _
HH16. Field editor's name and number:
____ Name
_ _ _ Number
_ _ _ Number
HH17. Main data entry clerk's name and number:
____ Name
_ _ _ Number
_ _ _ Number
HH18 Record the time
_ _ Hour
_ _ Minutes
_ _ Minutes
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 list of household have been used.
HL1. Line number: _ _
HL2. Name: ____
HL3. What is the relation-ship of (name) to the head of household?
Relation: _ _
HL4. Is the (name) Male or Female?
[] 1. Male
[] 2. Female
[] 2. Female
HL5. What is (name's) date of birth?
Month (98 DK): _ _
Year (9998 DK): _ _ _ _
Year (9998 DK): _ _ _ _
HL6. How old is (name)?
Record in completed years. If age is 95 or above '95':
Age: _ _
For women age 15-49
HL7. Circle line no. if woman age 15-49.
For children age 0-4
HL7B. Circle line no. If age 0-4.
HL11. Is (name)'s natural mother alive
For children age 0-17 years
[] 1. Yes
[] 2. No (Go to HL13)
[] 8. DK (Go to HL13)
[] 2. No (Go to HL13)
[] 8. DK (Go to HL13)
HL12. Does (name)'s natural mother live in this household? _ _
If "Yes", record line no. of mother. If "No", record 00.
HL13. Is (name)'s natural father alive
[] 1. Yes
[] 2. No (Go to HL15)
[] 8. DK (Go to HL15)
[] 2. No (Go to HL15)
[] 8. DK (Go to HL15)
HL14. Does (name)'s natural father live in this household? _ _
If "Yes", record line no. of father. If "No", record 00.
HL15. Record line no. of mother from HL12 if indicated.
If HL12 is blank or '00' ask: who is the primary caretaker of (name)?
For children age 0-14
Number: _ _
[] Tick here if additional questionnaire used
Probe for additional household members. Probe especially for any infants or small children not listed, and others who may not be members of the family (such as servants, friends) but who usually live in the household. Insert names of additional members in the household list and complete form accordingly.
Now for each woman age 15-49 years, write her name and line number and other identifying information in the information panel of a separate individual women's questionnaire.
For each 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.
Codes 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. DK
[] 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. DK
Education: ED
ED1. Line number: _ _
ED2. Name and age
Copy from HL2 and HL6.
Name: ____
Age: _ _
Age: _ _
ED3. Has (name) ever attended school or pre-school?
For household members age 5 and above
[] 1. Yes
[] 2. No (Go to next line)
[] 2. No (Go to next line)
ED4A. What is the highest level of school (name) has ever attended?
For household members age 5 and above. If level=0, skip to ED5
[] 0. Preschool
[] 1. Primary (1-4)
[] 2. Lower secondary (5-9)
[] 3. Upper secondary (10-11)
[] 4. Technical and professional
[] 5. Higher
[] 8. DK
[] 1. Primary (1-4)
[] 2. Lower secondary (5-9)
[] 3. Upper secondary (10-11)
[] 4. Technical and professional
[] 5. Higher
[] 8. DK
ED4B. What is the highest grade (name) completed at this level?
For household members age 5 and above. If the first grade at this level is not completed, enter "00".
Grade: _ _
[]98. DK
[]98. DK
ED5. During the current school year, that is 2015-2016, did (name) attend school or preschool at any time?
For household members age 5-24 years
[] 1. Yes
[] 2. No (Go to ED7)
[] 2. No (Go to ED7)
ED6. During this/that school year, which level and grade is/was (name) attending?
For household members age 5-24 years. If level=0 skip to ED7
Level:
[] 0. Preschool
[] 1. Primary (1-4)
[] 2. Lower secondary (5-9)
[] 3. Upper secondary (10-11)
[] 4. Technical and professional
[] 5. Higher
[] 8. DK
[] 1. Primary (1-4)
[] 2. Lower secondary (5-9)
[] 3. Upper secondary (10-11)
[] 4. Technical and professional
[] 5. Higher
[] 8. DK
Grade:
_ _
[] 98. DK
[] 98. DK
ED7. During the previous school year, that is 2014-2015, did (name) attend school or preschool at any time?
For household members age 5-24 years
[] 1. Yes
[] 2. No (Go to next line)
[] 8. DK (Go to next line)
[] 2. No (Go to next line)
[] 8. DK (Go to next line)
ED8. During that previous school year, which level and grade did (name) attend?
For household members age 5-24 years
If level=0 go to next line
Level:
[] 0. Preschool
[] 1. Primary (1-4)
[] 2. Lower secondary (5-9)
[] 3. Upper secondary (10-11)
[] 4. Technical and professional
[] 5. Higher
[] 8. DK
[] 1. Primary (1-4)
[] 2. Lower secondary (5-9)
[] 3. Upper secondary (10-11)
[] 4. Technical and professional
[] 5. Higher
[] 8. DK
Grade:
_ _
[] 98. DK
[] 98. DK
Selection of One Child For Child Discipline: SL
SL1. Check HL6 in the list of household members and write the total number of children age 1-14 years.
Total number: _
SL2. Check the number of children age 1-14 years in SL1:
[] Zero (Go to household characteristics module.)
[] One (Go to SL9 and record the rank number as "1", enter the line number from HL1, child's name from HL2 and age from HL6.)
[] Two or more (Continue with SL2A.)
[] One (Go to SL9 and record the rank number as "1", enter the line number from HL1, child's name from HL2 and age from HL6.)
[] Two or more (Continue with SL2A.)
SL2A. List each of the children age 1-14 years below in the order they appear in the List of household members. Do not include other household members outside of the age range 1-14 years. Record the line number, name, sex, and age for each child.
SL3. Rank number: _
SL4. Line number from HL1: _ _
SL5. Name from HL2: ____
SL6. Sex from HL4
[] 1. Male
[] 2. Female
[] 2. Female
SL7. Age from HL6: _ _
SL8. Check the last digit of the household number (HH2) from the cover page. This is the number of the row you should go to in the table below.
Check the total number of children age 1-14 years in SL1 above. This is the number of the column you should go to in the table below.
Find the box where the row and the column meet and circle the number that appears in the box. This is the rank number (SL3) of the selected child.
Last Digit of Household Number (from HH2): _
Total Number of Eligible Children in the Household (from SL1): [2 to 8+] _
Total Number of Eligible Children in the Household (from SL1): [2 to 8+] _
SL9. Record the rank number (SL3), line number (SL4), name (SL5) and age (SL7) of the selected child.
Rank number: _
Line number: _ _
Name: ____
Age: _ _
Line number: _ _
Name: ____
Age: _ _
Child Discipline: CD
CD3. Adults use certain ways to teach children the right behaviour or to address a behaviour problem. I will read various methods that are used. Please tell me if you or anyone else in your household has used this method with (name) in the past month.
[A] Took away privileges, forbade something (name) liked or did not allow him/her to leave the house.
[] 1. Yes
[] 2. No
[] 2. No
[B] Explained why (name)'s behaviour was wrong.
[] 1. Yes
[] 2. No
[] 2. No
[C] Shook him/her.
[] 1. Yes
[] 2. No
[] 2. No
[D] Shouted, yelled at or screamed at him/her.
[] 1. Yes
[] 2. No
[] 2. No
[E] Gave him/her something else to do.
[] 1. Yes
[] 2. No
[] 2. No
[F] Spanked, hit or slapped him/her on the bottom with bare hand.
[] 1. Yes
[] 2. No
[] 2. No
[G] Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.
[] 1. Yes
[] 2. No
[] 2. No
[H] Called him/her dumb, lazy, or another name like that.
[] 1. Yes
[] 2. No
[] 2. No
[I] Hit or slapped him/her on the face, head or ears.
[] 1. Yes
[] 2. No
[] 2. No
[J] Hit or slapped him/her on the hand, arm, or leg.
[] 1. Yes
[] 2. No
[] 2. No
[K] Beat him/her up, that is hit him/her over and over as hard as one could.
[] 1. Yes
[] 2. No
[] 2. No
CD4. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?
[] 1. Yes
[] 2. No
[] 8. DK/no opinion
[] 2. No
[] 8. DK/no opinion
Household Characteristics: HC
HC1B. What is the mother tongue/native language of the head of this household?
[] 1. Kazakh Language
[] 2. Russian Language
[] 6. Other language (specify) ____
[] 2. Russian Language
[] 6. Other language (specify) ____
HC1C. To what ethnicity does the head of this household belong?
[] 1. Kazakhs
[] 2. Russians
[] 6. Other ethnic group (specify) ____
[] 2. Russians
[] 6. Other ethnic group (specify) ____
HC2. How many rooms in this household are used for sleeping?
Number of rooms: _ _
HC3. Main material of the dwelling floor.
Record observation.
Rudimentary floor
[] 21. Wood planks
Finished floor
[] 31. Parquet or polished wood
[] 32. Vinyl/linoleum or asphalt strips
[] 33. Ceramic tiles
[] 34. Cement
[] 35. Carpet
[] 36. Laminated flooring board
[] 37. Plywood/fibreboard
[] 32. Vinyl/linoleum or asphalt strips
[] 33. Ceramic tiles
[] 34. Cement
[] 35. Carpet
[] 36. Laminated flooring board
[] 37. Plywood/fibreboard
[] 96. Other (specify) ____
HC4. Main material of the roof.
Record observation.
Rudimentary roofing
[] 23. Wood planks
[] 24. Cardboard/wood chipboard
[] 24. Cardboard/wood chipboard
Finished roofing
[] 31. Metal/profiled sheeting
[] 32. Wood
[] 33. Calamine/cement fiber mat/roofing slate
[] 34. Ceramic tiles
[] 35. Cement
[] 36. Roofing shingles
[] 96. Other (specify) ____
[] 32. Wood
[] 33. Calamine/cement fiber mat/roofing slate
[] 34. Ceramic tiles
[] 35. Cement
[] 36. Roofing shingles
[] 96. Other (specify) ____
HC5. Main material of the exterior walls.
Record observation
Rudimentary walls
[] 22. Stone with mud
[] 23. Uncovered adobe
[] 24. Plywood/wood chipboard
[] 26. Reused wood
[] 23. Uncovered adobe
[] 24. Plywood/wood chipboard
[] 26. Reused wood
Finished Walls
[] 31. Cement
[] 32. Stone with lime/cement
[] 33. Bricks
[] 34. Cement bricks
[] 35. Covered adobe
[] 36. Wood planks/shingles/lining boards
[] 37. Plastic panels/siding
[] 38. Wood
[] 39. Slag stone/concrete block
[] 32. Stone with lime/cement
[] 33. Bricks
[] 34. Cement bricks
[] 35. Covered adobe
[] 36. Wood planks/shingles/lining boards
[] 37. Plastic panels/siding
[] 38. Wood
[] 39. Slag stone/concrete block
[] 96. Other (specify) ____
HC6. What type of fuel does your household mainly use for cooking?
[] 01. Electricity (Go to HC8)
[] 02. Liquefied gas (in balloon) (Go to HC8)
[] 03. Natural gas (Go to HC8)
[] 04. Biogas (Go to HC8)
[] 05. Kerosene/diesel oil (Go to HC8)
[] 06. Coal/lignite
[] 07. Charcoal
[] 08. Wood
[] 10. Animal dung
[] 95. No food cooked in household (Go to HC8)
[] 96. Other (specify) ____
[] 02. Liquefied gas (in balloon) (Go to HC8)
[] 03. Natural gas (Go to HC8)
[] 04. Biogas (Go to HC8)
[] 05. Kerosene/diesel oil (Go to HC8)
[] 06. Coal/lignite
[] 07. Charcoal
[] 08. Wood
[] 10. Animal dung
[] 95. No food cooked in household (Go to HC8)
[] 96. Other (specify) ____
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?
In the house
[] 1. In a separate room used as kitchen
[] 2. Elsewhere in the house
[] 2. Elsewhere in the house
[] 3. In a separate building
[] 4. Outdoors
[] 6. Other (specify) ____
[] 4. Outdoors
[] 6. Other (specify) ____
HC8. Does your household have:
[A] Electricity?
[] 1. Yes
[] 2. No
[] 2. No
[B] A radio?
[] 1. Yes
[] 2. No
[] 2. No
[C] A television?
[] 1. Yes
[] 2. No
[] 2. No
[D] A non-mobile telephone?
[] 1. Yes
[] 2. No
[] 2. No
[E] A refrigerator?
[] 1. Yes
[] 2. No
[] 2. No
[F] A microwave?
[] 1. Yes
[] 2. No
[] 2. No
[G] A table?
[] 1. Yes
[] 2. No
[] 2. No
[H] A sofa?
[] 1. Yes
[] 2. No
[] 2. No
[I] A bed?
[] 1. Yes
[] 2. No
[] 2. No
[J] A wardrobe?
[] 1. Yes
[] 2. No
[] 2. No
[K] A dishwasher?
[] 1. Yes
[] 2. No
[] 2. No
[L] A washing machine?
[] 1. Yes
[] 2. No
[] 2. No
[M] An air conditioner?
[] 1. Yes
[] 2. No
[] 2. No
[N] A vacuum cleaner?
[] 1. Yes
[] 2. No
[] 2. No
HC9. Does any member of your household own:
[B] A mobile telephone or smartphone?
[] 1. Yes
[] 2. No
[] 2. No
[C] A bicycle?
[] 1. Yes
[] 2. No
[] 2. No
[D] A motorcycle or scooter?
[] 1. Yes
[] 2. No
[] 2. No
[E] An animal-drawn cart?
[] 1. Yes
[] 2. No
[] 2. No
[F] A car or truck?
[] 1. Yes
[] 2. No
[] 2. No
[J] A tractor?
[] 1. Yes
[] 2. No
[] 2. No
[G] A boat with a motor?
[] 1. Yes
[] 2. No
[] 2. No
[H] A personal computer or laptop?
[] 1. Yes
[] 2. No
[] 2. No
[I] A tablet?
[] 1. Yes
[] 2. No
[] 2. No
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".
[] 1. Own
[] 2. Rent
[] 6. Other (specify) ____
[] 2. Rent
[] 6. Other (specify) ____
HC11. Does any member of this household own any land that can be used for agriculture?
[] 1. Yes
[] 2. No (Go to HC13)
[] 2. No (Go to HC13)
HC12. How many hectares or ares of agricultural land do members of this household own?
If 1 hectare or more, circle ?1? and record hectares. If 95 or more hectares, circle ?1? and record ?95?. If less than 1 hectare, circle ?2? and record in ares. If less than 1 are, circle ?2? and record ?00?. If unknown, circle ?998?.
[] 1 Hectares: _ _
[] 2 Ares: _ _
[] 998 DK
[] 2 Ares: _ _
[] 998 DK
HC13. Does this household own any livestock, herds, other farm animals, or poultry?
[] 1. Yes
[] 2. No (Go to HC15)
[] 2. No (Go to HC15)
HC14. How many of the following animals/poultry does this household have?
If none, record '00'. If 95 or more, record '95'. If unknown, record '98'.
[A] Cows or bulls?
Numbers: _ _
[B] Horses or donkeys or mules?
Numbers: _ _
[C] Goats?
Numbers: _ _
[D] Sheep or rams?
Numbers: _ _
[E] Chickens?
Numbers: _ _
[F] Pigs?
Numbers: _ _
[G] Camels?
Numbers: _ _
[H] Geese or ducks?
Numbers: _ _
[I] Rabbits?
Numbers: _ _
HC15. Does any member of this household have a bank account?
[] 1. Yes
[] 2. No
[] 2. No
Water and Sanitation: WS
WS1. What is the main source of drinking water for members of your household?
Piped water
[] 11. Piped into dwelling (Go to WS6)
[] 12. Piped into compound, yard or plot (Go to WS6)
[] 13. Piped to neighbour (Go to WS6)
[] 14. Public tap/standpipe (Go to WS3)
[] 12. Piped into compound, yard or plot (Go to WS6)
[] 13. Piped to neighbour (Go to WS6)
[] 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)
Water from spring
[] 41. Protected spring (Go to WS3)
[] 42. Unprotected spring (Go to WS3)
[] 42. Unprotected spring (Go to WS3)
[] 51. Rainwater collection (Go to WS3)
[] 61. Tanker-truck (Go to WS3)
[] 71. Cart with small tank/drum (Go to WS3)
[] 81. Surface water (river, stream, dam, lake, pond, canal, irrigation channel) (Go to WS3)
[] 91. Bottled water
[] 96. Other (specify) ____(Go to WS3)
[] 61. Tanker-truck (Go to WS3)
[] 71. Cart with small tank/drum (Go to WS3)
[] 81. Surface water (river, stream, dam, lake, pond, canal, irrigation channel) (Go to WS3)
[] 91. Bottled water
[] 96. Other (specify) ____(Go to WS3)
WS2. What is the main source of water used by your household for other purposes such as cooking and handwashing?
Piped water
[] 11. Piped into dwelling (Go to WS6)
[] 12. Piped into compound, yard or plot (Go to WS6)
[] 13. Piped to neighbour (Go to WS6)
[] 14. Public tap/standpipe
[] 12. Piped into compound, yard or plot (Go to WS6)
[] 13. Piped to neighbour (Go to WS6)
[] 14. Public tap/standpipe
[] 21. Tube well, borehole
Dug Well
[] 31. Protected well
[] 32. Unprotected well
[] 32. Unprotected well
Water from spring
[] 41. Protected spring
[] 42. Unprotected spring
[] 42. Unprotected spring
[] 51. Rainwater collection
[] 61. Tanker-truck
[] 71. Cart with small tank/drum
[] 81. Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96. Other (specify) ____
[] 61. Tanker-truck
[] 71. Cart with small tank/drum
[] 81. Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96. Other (specify) ____
WS3. Where is that water source located?
[] 1. In own dwelling (Go to WS6)
[] 2. In own yard/plot (Go to WS6)
[] 3. Elsewhere
[] 2. In own yard/plot (Go to WS6)
[] 3. Elsewhere
WS4. How long does it take to go there, get water, and come back?
Number of minutes: _ _ _
[] 998. DK
[] 998. DK
WS5. Who usually goes to this source to collect the water for your household?
Probe: is this person under age 15? What sex?
[] 1. Adult woman (age 15+ years)
[] 2. Adult man (age 15+ years)
[] 3. Female child (Under 15)
[] 4. Male child (Under 15)
[] 8. DK
[] 2. Adult man (age 15+ years)
[] 3. Female child (Under 15)
[] 4. Male child (Under 15)
[] 8. DK
WS6. Do you do anything to the water to make it safer to drink?
[] 1. Yes
[] 2. No (Go to WS8)
[] 8. DK (Go to WS8)
[] 2. No (Go to WS8)
[] 8. DK (Go to WS8)
WS7. What do you usually do to make the water safer to drink?
Probe: Anything else?
Record all items mentioned.
[] A. Boil
[] B. Add bleach/chlorine
[] C. Strain it through a cloth/cotton
[] D. Use water filter (ceramic, sand, composite, etc.)
[] E. Solar disinfection
[] F. Let it stand and settle
[] X. Other (specify) ____
[] Z. DK
[] B. Add bleach/chlorine
[] C. Strain it through a cloth/cotton
[] D. Use water filter (ceramic, sand, composite, etc.)
[] E. Solar disinfection
[] F. Let it stand and settle
[] X. Other (specify) ____
[] Z. DK
WS8. What kind of toilet facility do members of your household usually use?
If "flush" or "pour flush", probe: Where does it flush to?
If not possible to determine, ask permission to observe the facility.
Flush/pour flush
[] 11. Flush to piped sewer system
[] 12. Flush to septic tank
[] 13. Flush to pit (latrine)
[] 14. Flush to somewhere else
[] 15. Flush to unknown place/not sure/DK where
[] 12. Flush to septic tank
[] 13. Flush to pit (latrine)
[] 14. Flush to somewhere else
[] 15. Flush to unknown place/not sure/DK where
Pit latrine
[] 21. Ventilated improved pit latrine
[] 22. Pit latrine with slab
[] 23. Pit latrine without slab/open pit
[] 22. Pit latrine with slab
[] 23. Pit latrine without slab/open pit
[] 95. No facility, bush, field (Go to next module)
[] 96. Other (specify) ____
[] 96. Other (specify) ____
WS9. 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)
WS10. Do you share this facility only with members of other households that you know, or is the facility open to the use of the general public?
[] 1. Other households only (not public)
[] 2. Public facility (Go to next module)
[] 2. Public facility (Go to next module)
WS11. How many households in total use this toilet facility, including your own household?
Number of households (if less than 10): 0_
[] 10. Ten or more households
[] 98. DK
[] 10. Ten or more households
[] 98. DK
Handwashing: HW
HW1. We would like to learn about the places that households use to wash their hands.
Can you please show me where members of your household most often wash their hands?
[] 1. Observed
Not Observed
Not Observed
[] 2. Not in dwelling/plot/yard (Go to HW4)
[] 3. No permission to see (Go to HW4)
[] 6. Other reason (specify) ____ (Go to HW4)
[] 3. No permission to see (Go to HW4)
[] 6. Other reason (specify) ____ (Go to HW4)
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
HW3A. Is soap or detergent present at the place for handwashing?
[] 1. Yes, present
[] 2. No, not present (Go to HW4)
[] 2. No, not present (Go to HW4)
HW3B. Record you observation.
Circle all that apply.
[] A. Bar soap (Go to HH19)
[] B. Detergent (powder/liquid/paste) (Go to HH19)
[] C. Liquid soap (Go to HH19)
[] B. Detergent (powder/liquid/paste) (Go to HH19)
[] C. Liquid soap (Go to HH19)
HW4. Do you have any soap or detergent in your house for washing hands?
[] 1. Yes
[] 2. No (Go to HH19)
[] 2. No (Go to HH19)
HW5A. Can you please show it to me?
[] 1. Yes, shown
[] 2. No, not shown (Go to HH19)
[] 2. No, not shown (Go to HH19)
HW5B. Record your observation.
Circle all that apply.
[] A. Bar soap
[] B. Detergent (powder/liquid/paste)
[] C. Liquid soap
[] B. Detergent (powder/liquid/paste)
[] C. Liquid soap
HH19. Record the time
Hour and minutes: _ _:_ _
Salt Iodization: SI
SI1. We would like to check whether the salt used in your household is iodized. 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.
[] 1. Not iodized - 0 PPM
[] 2. More than 0 PPM and less than 15 PPM
[] 3. 15 PPM or more
[] 4. No salt in the house
[] 5. Salt not tested (specify reason) ____
[] 2. More than 0 PPM and less than 15 PPM
[] 3. 15 PPM or more
[] 4. No salt in the house
[] 5. Salt not tested (specify reason) ____
HH20. Thank the respondent for his/her cooperation and check the list of household members:
[] A separate questionnaire for individual women has been issued for each woman age 15-49 years in the list of household members (HL7).
[] A separate questionnaire for children under five has been issued for each child under age 5 years in the list of household members (HL7B).
Return to the cover page and make sure that the result of the household interview (HH9), the name and line number of the respondent to the household questionnaire (HH10), and the number of eligible women (HH12), and under-5s (HH14) are entered. Make arrangements for the administration of the remaining questionnaire(s) in this household.
Interviewer's Observations ________
Field Editor's Observations ________
Supervisor's Observations ________