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Household Questionnaire

2017 Lao Social Indicator Survey (LSIS II)

Household Information Panel: HH

HH1. Cluster number: _ _ _ _

HH2. Household number: _ _

HH3. Interviewer's name and number:

Name ____
Number _ _ _

HH4. Supervisor's name and number:

Name ____
Number _ _ _

HH5. Day/Month/Year of interview:

_ _/_ _ /201 _

HH6. Area

[] 1. Urban
[] 2. Rural with road
[] 3. Rural without road

HH7. Province name and code

Name ____
Code _ _

Province names and codes

[] 01 Vientiane Capital
[] 02 Phongsaly
[] 03 Luangnamtha
[] 04 Oudomxay
[] 05 Bokeo
[] 06 Luangprabang
[] 07 Huaphanh
[] 08 Xayabury
[] 09 Xiengkhuang
[] 10 Vientiane
[] 11 Borikhamxay
[] 12 Khammua
[] 13 Savannakhet
[] 14 Saravane
[] 15 Sekong
[] 16 Champasack
[] 17 Attapeu
[] 18 Xaysomboune

HH8. Is the household selected for questionnaire for men?

[] 1. Yes
[] 2. No

HH8A. Altitude (meter) of the cluster

Altitude _ _ _ _

HHB8. Is the household selected for anaemia testing?

[] 1. Yes
[] 2. No

HH9. Is the household selected for water quality testing?

[] 1. Yes
[] 2. No

HH10. Is the household selected for blank testing?

[] 1. Yes
[] 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

HH12. Hello, my name is (your name). We are from Lao Statistics Bureau/Ministry of Health. 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 30-45 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?

[] 1. Yes, permission is given (Go to list of household members)
[] 2. No, permission is not given (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) ____

HH47. Name and line number of the respondent to household questionnaire interview:

Name ____
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

List Of Household Members: HL

First complete HL2 for all members of the household. Then proceed with HL3 and HL4 vertically. 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: ____

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

Relation: _ _

HL4. Is (name) male or female?

[] 1. Male
[] 2. Female

HL5. What is (name)'s date of birth?

Month (DK98): _ _
Year (DK9998): _ _ _

HL6. How old is (name)?
Record in completed years.
If age is 95 or above, record "95".

Age _ _

HL7. Did (name) stay here last night?

[] 1. Yes
[] 2. No

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

HL9. Record line number if man, age 15-49 and HH8 is yes: _ _

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

HL11. Age 0-17?

[] 1. Yes
[] 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)

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

[] 1. Yes
[] 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 province
[] 3. In another household in another province
[] 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)

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

[] 1. Yes
[] 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 province
[] 3. In another household in another province
[] 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

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: _ _

ED3. Age 3 or above?

[] 1. Yes
[] 2. No (Go to next line)

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

[] 1. Yes
[] 2. No (Go to next line)

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. Post secondary non tertiary
[] 5. Tertiary edu.
[] 8. DK
Grade/year:

[] 11-15. Primary
[] 21-24. Low sec
[] 31-33 Up sec
[]41-43 Post sec non ter.
[]51-57 Tertiary
[] 98. DK (Go to ED7)

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

[] 1. Yes
[] 2. No
[] 8. DK

ED7. Age 3-24?

[] 1. Yes
[] 2. No (Go to next line)

ED8. Check ED4: Ever attended school or ECE?

[] 1. Yes
[] 2. No (Go to next line)

Education 2: ED

ED1. Line number _ _

ED2. Name and age

Name: ____
Age: _ _

ED9. At any time during the 2016-17 school year did (name) attend school or any early childhood education programme?

[] 1. Yes
[] 2. No (Go to ED15)

ED10. During 2016-17 school year, which level and grade or year is (name) attending?

Level

[] 0. ECE (Go to ED15)
[] 1. Primary
[] 2. Lower sec.
[] 3. Upper sec.
[] 4. Post secondary non tertiary
[] 5. Tertiary edu.
[] 8. DK
Grade/year:

[] 11-15. Primary
[] 21-24. Low sec
[] 31-33 Up sec
[]41-43 Post sec non ter.
[]51-57 Tertiary
[] 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. Govt/public
[] 2. Religious/faith organization
[] 3. Private
[] 6. Other
[] 8. DK

ED12. In the 2016-17 school year, 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)

ED13. Who provided the tuition support?
Record all mentioned.

[] A. Govt/public
[] B. Religious/faith organization
[] C. Private
[] X. Other
[] Z. DK

ED14. For the 2016-17 school year, 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

ED15. At any time during the 2015-16 school year did (name) attend school or any early childhood education programme?

[] 1. Yes
[] 2. No (Go to next line)
[] 8. DK (Go to next line)

ED16. During 2015-16 school year, 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. Post secondary non tertiary
[] 5. Tertiary edu.
[] 8. DK
Grade/Year:
[] 11-15. Primary
[] 21-24. Low sec
[] 31-33 Up sec
[]41-43 Post sec non ter.
[]51-57 Tertiary
[] 98. DK

Household Characteristics: HC

HC1A. What is the religion of (name of the head of the household from HL2)?

[] 1. Buddhist
[] 2. Christianity
[] 3. Islam
[] 4. Animist
[] 6. Other Religion (specify) ____
[] 7. No Religion

HC2. To what ethnic group does (name of the head of the household from HL2) belong?

_ _ Ethnic group code
[] 96. Other (specify) ____

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. Earth/sand
[] 12. Dung
Rudimentary floor
[] 21. Wood planks
[] 22. Palm/bamboo
Finished Floor
[] 31. Parquet or polished wood
[] 32. Vinyl or asphalt strips
[] 33. Ceramic Tiles
[] 34. Cement
[] 35. Carpet
[] 96. Other (specify) ____

[page 6]

HC5. Main material of the roof.
Record observation.

Natural roofing
[] 11. No roof
[] 12. Thatch/palm leaf
[] 13. Sod
Rudimentary roofing
[] 22. Palm/bamboo
[] 23. Wood planks
[] 24. Cardboard
Finished roofing
[] 31. Metal/tin
[] 32. Wood
[] 33. Calamine/cement fibre
[] 34. Ceramic tiles
[] 35. Cement
[] 36. Roofing shingles
[] 96. Other (specify) ____

HC6. Main material of the exterior walls.
Record observation.

Natural walls
[] 11. No walls
[] 12. Cane/palm/trunks
[] 13. Dirt
Rudimentary walls
[] 21. Bamboo with mud
[] 24. Plywood
[] 25. Cardboard
[] 26. Reused wood
[] 27. Bamboo mat
[] 28. Bamboo/bamboo with dry leaf
[] 29. Bamboo lattice
Finished Walls
[] 31. Cement
[] 32. Stone with lime/cement
[] 33. Bricks
[] 34. Cement bricks
[] 36. Wood planks/shingles
[] 96. Other (specify) ____

HC7. Does your household have:

A. A fixed telephone line?

[] 1. Yes
[] 2. No

B. A radio?

[] 1. Yes
[] 2. No

C. Clock

[] 1. Yes
[] 2. No

D. Sofa/wooden settee

[] 1. Yes
[] 2. No

E. Bed/mattress

[] 1. Yes
[] 2. No

HC8. Does your household have electricity?

[] 1. Yes, Interconnected gird
[] 2. Yes, off-grid (generator/isolated system)
[] 3. No (Go to HC10)

HC9. Does your household have:

A. A television?

[] 1. Yes
[] 2. No

B. A refrigerator?

[] 1. Yes
[] 2. No

C. Fan

[] 1. Yes
[] 2. No

D. Water pump

[] 1. Yes
[] 2. No

E. Air--conditioner

[] 1. Yes
[] 2. No

F. Washing machine

[] 1. Yes
[] 2. No

G. CD/DVD player/home theatre

[] 1. Yes
[] 2. No

H. Iron

[] 1. Yes
[] 2. No

I. Rice cooker/steamed cooker

[] 1. Yes
[] 2. No


HC10. Does any member of your household own:

A. A watch?

[] 1. Yes
[] 2. No

B. A bicycle?

[] 1. Yes
[] 2. No

C. A motorcycle or scooter?

[] 1. Yes
[] 2. No

D. An animal-drawn cart?

[] 1. Yes
[] 2. No

E. A car, truck or van?

[] 1. Yes
[] 2. No

F. A boat with a motor?

[] 1. Yes
[] 2. No

G. Tak Tak

[] 1. Yes
[] 2. No

HC11. Does any member of your household have a computer or a tablet?

[] 1. Yes
[] 2. No

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

[] 1. Yes
[] 2. No

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

[] 1. Yes
[] 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. Own
[] 2. Rent
[] 6. Other (specify) _____

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

[] 1. Yes
[] 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

HC17. Does this household own any livestock, herds, other farm animals, or poultry?

[] 1. Yes
[] 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. Cattle? (cow/buffalo)

Number: _ _

D. Goats?

Number: _ _

E. Sheep?

Number: _ _

F. Chickens? / Ducks?

Number: _ _

G. Pigs?

Number: _ _

H. Others? (specify) ____)

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

[] 1. Yes
[] 2. No

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. National social security fund (state authority for social security, social security organization)
[] 1. Yes
[] 2. No (Go to B)
B. National social security fund (community based health insurance, health equity fund, free mother and child)
[] 1. Yes
[] 2. No (Go to C)
C. Free school fees
[] 1. Yes
[] 2. No (Go to D)
D. Any retirement pension
[] 1. Yes
[] 2. No (Go to X)
X. Any other external assistance programme
[] 1. Yes (specify) ____
[] 2. No (Go to end of module)

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

A. National social security fund (state authority for social security, social security organization)
[] 1. Yes (Go to ST4)
[] 2. No (Go to B)
[] 8. DK (Go to B)
B. National social security fund (community based health insurance, health equity fund, free mother and child)
[] 1. Yes (Go to ST4)
[] 2. No (Go to C)
[] 8. DK (Go to C)
C. Free school fees
[] 1. Yes (Go to ST4)
[] 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)
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)

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. National social security fund (state authority for social security, social security organization
1. Months ago _ _ (Go to B)
2. Years ago_ _ (Go to B)
[] 998. DK (Go to B)
B. National social security fund (community based health insurance, health equity fund, free mother and child)
1. Months ago _ _ (Go to C)
2. Years ago_ _ (Go to C)
[] 998. DK (Go to C)
C. Free school fees
1. Months ago _ _ (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)
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)

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)
[] 05. Biogas 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

EU3. Does it have a fan?

[] 1. Yes
[] 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/diesel
[] 03. Kerosene/paraffin
[] 04. Coal/lignite
[] 05. Charcoal
[] 06. Wood
[] 07. Crop residue/grass/straw/shrubs
[] 08. Animal dung/waste
[] 09. Processed biomass (pellets) or woodchips
[] 10. Garbage/plastic
[] 11. Sawdust
[] 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
Outdoors
[] 04. Open air
[] 05. On veranda or covered porch
[] 06. Other (specify) ____

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)

EU7. Does it have a chimney?

[] 1. Yes
[] 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
[] 05. Biogas
[] 06. Alcohol/ethanol
[] 07. Gasoline/diesel
[] 08. Kerosene/paraffin
[] 09. Coal/lignite
[] 10. Charcoal
[] 11. Wood
[] 12. Crop residue/grass/straw/shrubs
[] 13. Animal dung/waste
[] 14. Processed biomass (pellets) or woodchips
[] 15. Garbage/plastic
[] 16. Sawdust
[] 96. Other (specify) ____

EU9. At night, what does your household mainly use to light the household?

[] 1. Electricity
[] 2. Solar lantern
[] 3. Rechargeable flashlight, torch or lantern
[] 4. Battery powered flashlight, torch or lantern
[] 5. Biogas lamp
[] 6. Gasoline lamp
[] 7. Kerosene or paraffin lamp
[] 8. Charcoal
[] 9. Wood
[] 10. Crop residue/grass/straw/shrubs
[] 11. Animal dung/waste
[] 12. Oil lamp
[] 13. Candle
[] 96. Other (specify) ____
[] 97. No lighting in household

Insecticide treated nets: TN

TN1. Does your household have any mosquito nets?

[] 1. Yes
[] 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 six nets]

[] 1. Observed
[] 2. Not observed

TN4. How many months ago did your household get the mosquito net? [Up to six nets]
If less than one month, record "00".

Months ago: _ _
[] 95. More than 36 months ago
[] 98. DK/not sure

TN5. Observe or ask the brand/type of mosquito net. [Up to six 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 (LLIN)

[] 11. Olyset net
[] 12. Permanet net
[] 16. Other brand (specify) ____
[] 18. DK brand
[] 36. Other type (specify) ____
[] 98. DK brand/type

TN6. Is net type LLIN (TN5=11-18)? [Up to six nets]

[] 1. Yes (Go to TN10)
[] 2. No

TN7. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes? [Up to six nets]

[] 1. Yes
[] 2. No
[] 8. DK/Not sure

TN8. Was the net soaked or dipped (TN7=1)? [Up to six nets]

[] 1. Yes
[] 2. No (Go to TN10)

TN9. How many months ago was the net last soaked or dipped? [Up to six nets]
If less than one month, record '00'.

_ _ Months ago
[] 95. More than 24 months ago
[] 98. DK/Not sure

TN10. Did you get the net during an antenatal care visit, or during an immunization visit? [Up to six nets]

[] 2. Yes, ANC
[] 3. Yes, EPI
[] 4. No
[] 8. DK

TN11. Check TN10: Is TN10=4? [Up to six nets]

[] 1. Yes
[] 2. No (Go to TN13)

TN12. Where did you get the net? [Up to six 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


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

[] 1. Yes
[] 2. No
[] 8. DK/not sure

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

[] 1. Yes
[] 2. No (Go to TN16)

TN15. Who slept under this mosquito net last night? [Up to six 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
____ Name 2
_ _ Line number
____ Name 3
_ _ Line number
____ Name 4
_ _ Line number

TN16. Is there another net? [Up to six nets]

[] 1. Yes (Go to next net)
[] 2. No (Go to end of module)

[] Tick here if additional questionnaire used

Water and sanitation: WS

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 to 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)
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)
Packaged water
[] 91. Bottled water
[] 92. Sachet 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
Dug well
[] 31. Protected 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)
[] 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

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

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: _ _

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

Number of times: _ _
[] 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)

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

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)

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

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)
[] 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)
[] 95. No facility/bush/field (Go to next module)
[] 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)
[] 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
Emptied by household
[] 4. Buried in a covered pit
[] 5. To uncovered pit, open ground, water body or elsewhere
[] 6. Other (specify) ____
[] 8. DK

WS14. Where is this toilet facility located?

[] 1. In own dwelling
[] 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)

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)


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

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)
Not observed
[] 4. No handwashing place in dwelling/yard/plot (Go to HW5)
[] 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

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)

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
[] 3. Mobile object (bucket/jug/kettle)
[] 4. No handwashing place in dwelling/yard/plot
[] 6. Other (specify) ____

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

[] 1. Yes
[] 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)

HW7. Record your observation.
Record all that apply.

[] A. Bar or liquid soap
[] B. Detergent (powder/liquid/paste)
[] C. Ash/sand

Salt Iodisation: SA

SA1. 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?
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 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)

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)
Salt not tested
[] 6. Other reason (specify) ____

HH13. Record the time.

Hours and minutes: _ _:_ _


HH14. Language of the Questionnaire.

[] 1. Lao

HH15. Language of the Interview.

[] 1. Lao
[] 6. Other language (specify) ____

HH16. Native language of the Respondent.

[] 1. Lao
[] 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

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): _

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

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): _

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

Rank number: _
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: _ _

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

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)

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)

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 equals 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.

HH34. Check HH8 in the household information panel: Is the household selected for Questionnaire for Men?

[] 1. Yes, HH8=1
[] 2. No, HH8=0 (Go to HH40)

HH35. Check HL9 in the "List of household members": Are there any men age 15-49?

[] 1. Yes at least one man age 15-49
[] 2. No (Go to HH40)

HH36. Issue a separate questionnaire for individual men for each man age 15-49 years.

HH37. Check HL6 and HL8 in the list of household members: Are there any boys age 15-17?

[] 1. Yes, at least one boy age 15-17
[] 2. No (Go to HH40)

HH38. Check HL20 in the "List of household members": Is consent required for interviewing at least one boy age 15-17?

[] 1. Yes at least one boy age 15-17 with HL20 does not equal 90
[] 2. No, HL20 equals 90 for all boys age 15-17 (Go to HH40)

HH39. As part of the survey we are also interviewing men age 15-49. We ask each person we interview for permission. A male interviewer conducts these interviews.

For boys 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 male member(s) age 15-17) later?

[] "Yes" for all boys age 15-17. Continue with HH40.

[] "No" for at least one boy age 15-17 and "Yes" to at least one boy age 15-17. Record "06" in MWM17 (also in UF17 and FS17, if applicable) on individual questionnaires for those adult consent was not given. Then continue with HH40.

[] "No" for all boys age 15-17. Record "06" in MWM17 (also in UF17 and FS17, if applicable) on all individual questionnaires for whom adult consent was not given. Then continue with HH40.

[page 23]
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)

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)

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)

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.

Interviewer's Observations

Supervisor's Observations