We are from (the Republic of Montenegro/Research agency). 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

HH1. Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

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

HH6. Address of household

HH7. Telephone of Household (Must enter area code)

HH8. Name of head of household: ____

Interviewer: Go to module HL - List of household members on the inside of the folder cover in which you will put all questionnaires.
After all questionnaires for the household have been completed, fill in the following information:
[Note: HH9 to HH16]

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: _ _

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: ____

HL2A. Activity of household members:
[] 01 employed
[] 02 works outside official employment
[] 03 self-employed
[] 04 farmer
[] 05 unemployed
[] 06 pensioner
[] 07 housewife
[] 08 child, pupil, student
[] 09 lives abroad
[] 10 other

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

HL4. Is (name) male or female?

HL5. How old is (name)? How old was (name) in his/her last birthday?
Record in Completed years
HL5A. Date of (name?s) birth?
For each child and women write down at least the year of birth
[] 98 DK day
[] 98 DK month
[] 9998 DK year

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

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?

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.

1. Questionnaire for household ? questions from this questionnaire can be answered by any adult household.
HH1. Cluster number: _ _ _
HH2. Household number: _ _

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 the (YEAR) 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/that 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 (YEAR)?

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

ED9. Ask only for children who go to first grade of primary school: Did (name) attend preschool institution for at least 2 hours in 6 months during last 12?

ED10. What is the distance in kilometers from house/flat to school which (name of child) attend?
If school is located at distance less than 1 km, write down 000. If household member aged from 5 to 24 years does not live with parents, that is, if he/she attends school in other place, write down 998 and go to other household member.
ED11. How does (name of child) usually go to school?

ED12. What is (name of child?s) total monthly cost of transportation to school and back from school?
Write down answer in dinars.
ED13. How many minutes does (name of child) spend going to/from school?

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 handwashing?

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?

WS6. What do you usually do to the water to make it safer to drink?
Anything else?
Record all items mentioned. ?Z? is circled only if no answer is given
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. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

Household characteristics module: HC

HC1A. What is the religion of the head of this household?

HC1B. What is the mother tongue/native language of the head of this household?

HC1C. To what ethnic group does the head of this household belong?

HC2. What is the area of house/flat you live in? write down area in square meters
[] Area in square meters (Go to HC2A)

HC2A. How many rooms do you use in house/flat that you live in other than kitchen, hall and auxiliary rooms?

HC3. Main material of the dwelling floor:
Record observation.
HC4. Main material of the roof.
Record observation.

HC5. Main material of the walls.
Record observation.

HC6. What type of fuel does your household mainly use for cooking?

HC7. In this household, is food cooked on an open fire, an open stove or a closed stove?
Probe for type.
HC7A. Does the fire/stove have a chimney or a hood?

HC8. Is the cooking usually done in the house, in a separate building, or outdoors?

HC9. Does your household have:






A water heater?

A washing machine?

A dishwashing machine?

A computer?

An air conditioner?

A heating?

HC10. Does any member of your household own:
Read the list








HC10A. How would you evaluate the standard of your household? Do not read answers

HC10B. In your opinion, what is the minimal monthly amount needed to cover basic coasts of your household? If DK or not sure, write down ?999998?

HC11. Does any member of this household own any land that can be used for agriculture?

HC12. How many hectares of agricultural land do members of this household own?
If unknown, record '98'.
HC13. Does this household own any livestock, herds, or farm animals?

HC14. How many of the following animals does this household have?
[This question is from optional modules]








HC15A. Do you or someone in this household own this dwelling, or do you rent this dwelling?
For owners- write down line number from list of household members. If more than one owner- write down ?95?.

HC15B. Do you or someone in this household have a title deed, or sale contract for this dwelling?

HC15C. What kind of document do you have for the ownership of this dwelling?
Anything else?
Record all items mentioned.
HC15D. Do you have a written rental contract for this dwelling?

HC15E. Do you have any documentation or agreement for the rental of this dwelling? If yes, what kind of document or agreement do you have for the rental of this dwelling? Anything else?
If no documentation, ask on what basis they rent the dwelling.
Record all items mentioned.
HC15F. Do you feel secure from eviction from this dwelling?

HC15G. Have you been evicted from your home at any time during the past 15 years? If yes, probe: Has this happened only once, or more than once?

HC15H. Dwelling located in or near:
Observe, and circle all items that describe the location of dwelling. Multiple answer. Circle ?Y? only if none of the above
HC15I. Condition of dwelling:
Record observation. Record all that apply.
HC15J. Dwelling surroundings:
Multiple answer. Observe, and circle all items that describe the dwelling surroundings. Circle ?Y? only if none of the above.
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. During the past week did (name) 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: Since last (day of the week), about how many hours 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

Ask mother/caretaker questions from module CD- Child Discipline module for one child aged from 2 to 14 years. If no children of this age in the household, go to next module DA-Disability. If more than one child aged 2 to 14 years, the questions will refer to the child whose birthday comes first after the date of interview. Find this information in list of household members (Table HL-question HL5A). Ask questions for that particular child.
After establishing to which child the questions from this module will refer. Administer to mother/caretaker of this child.

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.

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, yelled at or screamed at him/her.

CD12E. Gave him/her something else to do.

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

CD12G. Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.

CD12H. Called him/her dumb, lazy, or another name like that.

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

CD12J. Hit or slapped him/her on the hand, arm, or leg.

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

CD13. Do you believe that in order to bring up (raise, educate) (name) properly, you need to physically punish him/her?

Disability: DA

To be administered to caretakers of all children 2 through 9 years old living in the household. For household members below age 2 or above age 9, leave rows blank
I would like to ask you if any children in this household aged 2 through 9 has any of the health conditions I am going to mention to you.

DA1. Line no.

DA2. Child's name

DA3. Compared with other children, does or did (name) have any serious delay in sitting, standing, or walking?

DA4. Compared with other children, does (name) have difficulty seeing, either in the daytime or at night?

DA5. Does (name) appear to have difficulty hearing? (uses hearing aid, hears with difficulty, completely deaf?)

DA6. When you tell (name) to do something, does he/she seem to understand what you are saying?

DA7. Does (name) have difficulty in walking or moving his/her arms or does he/she have weakness and/or stiffness in the arms or legs?

DA8. Does (name) sometimes have fits, become rigid, or lose consciousness?

DA9. Does (name) learn to do things like other children his/her age?

DA10. Does (name) speak at all (can he/she make him or herself understood in words; can say any recognizable words)?

DA11. (For 3-9 year olds): Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?

DA12. (For 2-year-olds): Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?

DA13. Compared with other children of the same age, does (name) appear in any way mentally backward, dull or slow?

SI2. Is there any eligible woman age 15-49 who lives in the household?
Check household listing, column HL6. You should have a questionnaire with the information panel filled in for each eligible woman.
[] Yes (Go to questionnaire for women aged from 15 to 49 years)
[] No (Go to SI3)

SI3. Are there any child under the age of 5 who live in the household?
Check household listing, column HL8. For each child who satisfies the condition it is necessary to have a previously prepared questionnaire for children under five with filled information panel.
[] Yes (Go to questionnaire for children under five.)
[] No (Collect all questionnaires for this household, put them in ?cover? and fill fields HH9-HH15 on the first page)