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MICS Household Questionnaire

[16 January 2012, v3.0]

[name of country]

Household Information Panel: HH

HH1. Cluster number: _ _ _

HH2. Household number: _ _

HH3. Interviewer name and number

Name: ____
Number: _ _

HH4. Supervisor name and number:

Name: ____
Number: _ _

HH5. Day/month/year of interview

_ _ / _ _ / _ _ _ _

HH6. Area

[] 1 Urban
[] 2 Rural

HH7. Region

[] 1 Region 1
[] 2 Region 2
[] 3 Region 3
[] 4 Region 4

We are from (country-specific affiliation). We are working on a project concerned with family health and education. I would like to talk to you about these subjects. The interview will take about (number) minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team. 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 (Complete HH9. Discuss this result with your supervisor.)

After all questionnaires for the household have been completed, fill in the following information:
[Note: for question HH8 to HH18]

HH8. Name of household: ____

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) ____ ____

HH10. Respondent to household questionnaire:

Name: ____
Line number: _ _

HH11. Total number of household members: _ _

HH12. Number of women age 15-49 years: _ _

HH13. Number of woman's questionnaires completed: _ _

HH12. Number of men age 15-49 years: _ _

HH13B. Number of men's questionnaires completed: _ _


HH14. Number of children under age 5: _ _

HH15. Number of under-5 questionnaires completed: _ _

HH16. Field edited by (name and number)

Name: ____
Line number: _ _

HH17. Date entry clerk (name and number)

Name: ____
Line number: _ _

HH18. Record the time

_ _ Hour
_ _ Minutes

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?

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 household listing form 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

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

Month: _ _
[] 98 DK
Year: _ _ _ _
[] 9988 DK

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

Age: _ _

HL7. Circle line no.
If woman is age 15-49 (for woman age 15-49)

HL7A. Circle line no.
If man is age 15-49 (for men age 15-49)

HL8. Who is the mother or primary caretaker of this child?
Record line no. of mother/caretaker (for children age 5-14.)

Mother: _ _

HL9. Who is the mother or primary caretaker of this child?
Record line no. of mother/ caretaker (for children under age 5)

Mother: _ _

HL10. Did (name) stay here last night?

[] 1 Yes
[] 2 No

For children age 0-17 years [HL11 to HL14]

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

[] 1 Yes
[] 2 No (Go to HL13)
[] 8 DK (Go to HL13)

HL12. Does (name's) natural mother live in this household?
Record line number of number or 00 for no

Mother: _ _

HL13. Is (name's) natural father alive?

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

HL14. Does (name's) natural father live in this household?
Record line no. of father or 00 for "no"

Father: _ _

[] tick here is 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 man age 15-49 years, write his name and line number and other identifying information in the information panel of a separate individual man'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, each eligible man, and each child under five in the household.

Code for HL3. Relationship to head of household

[] 01 Head
[] 02 Wife/husband
[] 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 Not related
[] 98 Don't know

Education: ED

For household member age 5 and above [ED1 to ED4B]

ED1. Line number: _ _

ED2. Name and age
Copy from Household Listing Form, HL2 and HL6

Name: ____
Age: _ _

ED3. Has (name) ever attended school or pre-school?

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

ED4A. What is the highest level of school (name) has attended?
If level=0, skip to ED5

Level
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK

ED4B. What is the highest grade (name) completed at this level?
If less than 1 grade, enter 00

Grade: _ _
[] 98 DK

For household members age 5-24 years [ED5 to ED8]

ED5. During the (2011-2012) school year, did (name) attend school or preschool at any time?

[] 1 Yes
[] 2 No (Go to ED7)

ED6. During this/that school year, which level and grade is/was (name) attending?
If level=0, skip to ED5

Level
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK
Grade: _ _
[] 98 DK

ED7. During the previous school year, that is (2010-2011), did (name) attend school or preschool at any time?

[] 1 Yes
[] 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?
If level=0, skip to ED5

Level
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK
Grade: _ _
[] 98. DK

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 into neighbourhood (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)
Water from spring
[] 41 Protected spring (Go to WS3)
[] 42 Unprotected spring (Go to WS3)
[] 51 Rainwater collector (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 into neighbourhood (Go to WS6)
[] 14 Public tap/standpipe
[] 21 Tube well, borehole
Dug well
[] 31 Protected well
[] 32 Unprotected well
Water from spring
[] 41 Protected spring
[] 42 Unprotected spring
[] 51 Rainwater collector
[] 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

WS4. How long does it take to go there, get water, and come back?

Number of minutes: _ _ _
[] 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

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)

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
[] D Use water filter (ceramic, sand, composite, ect.)
[] 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 necessary, 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
Pit latrine
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 31 Composting toilet
[] 41 Bucket
[] 51 Hanging toilet, hanging latrine
[] 95 No facility, bush, field (Go to next module)
[] 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)

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)

WS11. 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

Household characteristics: HC

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

[] 1 Religion 1
[] 2 Religion 2
[] 3 Religion 3
[] 6 Other religion (specify) ____
[] 7 No religion

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

[] 1 Language 1
[] 2 Language 2
[] 3 Language 3
[] 6 Other language (specify) ____

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

[] 1 Ethnic group 1
[] 2 Ethnic group 2
[] 3 Ethnic group 3
[] 6 Other ethnic group (specify) ____

HC2. How many rooms in this household are used for sleeping?

Number of rooms: _ _

HC3. Main material of dwelling floor
Record observation

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) ____ ____

HC4. Main material of the roof
Record observations

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

HC5. Main material of the exterior walls.
Record observations

Natural walls
[] 11 No walls
[] 12 Cane/palm/trunks
[] 13 Dirt
Rudimentary walls
[] 21 Bamboo with mud
[] 22 Stone with mud
[] 23 Uncovered adobe
[] 24 Plywood
[] 25 Cardboard
[] 26 Reused wood
Finished walls
[] 31 Cement
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement bricks
[] 35 Covered adobe
[] 36 Wood planks/shingles
[] 96 Other (specify) ____

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

[] 01 Electricity (Go to HC8)
[] 02 Liquefied petroleum gas (LPG) (Go to HC8)
[] 03 Natural gas (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene (Go to HC8)
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 10 Animal dung
[] 11 Agricultural crop residue
[] 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 a kitchen
[] 2 Elsewhere in the house
[] 3 In a separate building
[] 4 Outdoors
[] 6 Other (specify) ____

HC8. Does your household have:

A. Electricity?

[] 1 Yes
[] 2 No

B. A radio?

[] 1 Yes
[] 2 No

C. A television?

[] 1 Yes
[] 2 No

D. A non-mobile telephone?

[] 1 Yes
[] 2 No

E. A refrigerator?

[] 1 Yes
[] 2 No

HC9. Does any member of your household own:

A. A watch?

[] 1 Yes
[] 2 No

B. A mobile telephone?

[] 1 Yes
[] 2 No

C. A bicycle?

[] 1 Yes
[] 2 No

D. A motorcycle or scooter?

[] 1 Yes
[] 2 No

E. An animal drawn cart?

[] 1 Yes
[] 2 No

F. A car or truck?

[] 1 Yes
[] 2 No

G. A boat with a motor?

[] 1 Yes
[] 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 (not owned or rented)

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

[] 1 Yes
[] 2 No (Go to HC13)

HC12. How many hectares of agricultural land do members of this household own?
If less than one, record "00". If 95 or more, record '95'. If unknown, record '98'.

_ _ Hectares

HC13. Does this household own any livestock, herds, other farm animals, or poultry?

[] 1 Yes
[] 2 No (Go to HC15)

HC14. 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, milk cows, or bulls?

Numbers: _ _

B. Horses, donkeys, or mules?

Numbers: _ _

C. Goats?

Numbers: _ _

D. Sheep?

Numbers: _ _

E. Chickens?

Numbers: _ _

F. Pigs?

Numbers: _ _

HC15. Does any member of this household have a bank account?

[] 1. Yes
[] 2. No

Insecticide Treated Nets: TN

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

[] 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 the nets in the household. If more than 3 nets, use additional questionnaire(s).
[Repeat questions from modules TN4-TN13 for each net]

TN4. Mosquito net observed

[] 1 Observed
[] 2 Not observed

TN5. Observe or ask the brand/type of mosquito net.
If brand is unknown and you cannot observe the net, show pictures of typical net types/brands to respondent.

Long lasting treated nets
[] 11 Brand A
[] 12 Brand B
[] 13 Brand C
[] 16 Other (specify) ____
[] 18 DK brand
Pre-treated nets
[] 21 Brand D
[] 22 Brand E
[] 23 Brand F
[] 26 Other (specify) ____
[] 28 DK brand/type
[] 31 Other net (specify) ____
[] 98 DK brand/type

TN6. How many months ago did your household get the mosquito net?
If less than one month, record "00"

_ _ Months ago
[] 95 More than 36 mo ago
[] 98 DK/not sure

TN7. Check TN5 for type of net

[] Long lasting (11-18) (Go to TN11)
[] Pre-treated (21-28) (Go to TN9)
[] Else (Continue)

TN8. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

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

TN9. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

[] 1 Yes
[] 2 No (Go to TN11)
[] 8 DK/not sure (Go to TN11)

TN10. How many months ago was the net last soaked or dipped?
If less than one month, record "00"

_ _ Months ago
[] 95 More than 24 mo ago
[] 98 DK/not sure

TN11. Did anyone sleep under this mosquito net last night?

[] 1 Yes
[] 2 No (Go to TN13)
[] 8 DK/not sure (Go to TN13)

TN12. Who slept under this mosquito net last night?
Record the person's line number from the household listing form
If someone not in the household list slept under the mosquito net, record 00

____ Name
_ _ Line number

TN13.
1st Net: Go back to TN4 for next net. If no more nets, go to next module.
2nd Net: Go back to TN4 for next net. If no more nets, go to next module.
3rd Net: Go back to TN4 in first column of a new questionnaire for next net. If no more nets, go to next module.

[] Tick here if additional questions used

Indoor residual spraying: IR

IR1. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

[] 1 Yes
[] 2 No (Go to next module)
[] 8 DK/not sure (Go to next module)

IR2. Who sprayed the dwelling?
Circle all that apply.

[] A Government worker/program
[] B Private company
[] C Non-governmental organization
[] X Other (specify) ____
[] Z DK

Child Labour: CL

To be administered for children in the household age 5-14 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 number: _ _

CL2. Name and age copy from Household Listing Form, HL2 and HL6

____ Name
_ _ Age

CL3. During the past 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?

[] 1 Yes, for pay (cash or kind)
[] 2 Yes, unpaid
[] 3 No (Go to CL5)

CL4. 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?
If more than one job, include all hours at all jobs.

Number of hours: _ _

CL5. During the past week, did (name) fetch water or collect firewood for household use?

[] 1 Yes
[] 2 No (Go to CL7)

CL6. Since last (day of the week), about how many hours did he/she fetch water or collect firewood for household use?

Number of hours: _ _

CL7. During the past week, did (name) do any paid or unpaid work on a family farm or in a family business or selling goods in the street?
Include work for a business run by the child, alone or with one or more partners.

[] 1 Yes
[] 2 No (Go to CL9)

CL8. Since last (day of the week), about how many hours did he/she do this work for his/her family or himself/herself?

Number of hours: _ _

CL9. During the past week, did (name) help with household chores such as shopping, cleaning, washing clothes, cooking; or caring for children, old or sick people?

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

CL10. Since last (day of the week), about how many hours did he/she spend doing these chores?

Number of hours: _ _

Child Discipline: CD

Table 1: Children Aged 2-14 Years Eligible for Child Discipline Questions
List each of the children aged 2-14 years below in the order they appear in the household listing form. Do not include other household members outside of the age range 2-14 years.
Record the line number, name, sex, and age for each child.
Then record the total number of children aged 2-14 in the box provided (CD6).
If there are no children age 2-14 years in the household, skip to next module.
If there is only one child age 2-14 years in the household, then skip table 2 and go to CD8; write down'1' and continue with CD9.

CD1. Rank Number: _

CD2. Line number from HL1: _ _

CD3. Name from HL2: ____

CD4. Sex from HL4

[] 1 Male
[] 2 Female

CD5. Age from HL6: _ _

CD6. Total children age 2-14 years: _ _

Table 2: Selection of Random Child for Child Discipline Questions
Use Table 2 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.
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 eligible children (2-14) in CD6 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 (CD1) about whom the questions will be asked.

CD7.
Total number of eligible children in the household (CD6) [Column 1 to 8+]
Last digit of household number (HH2) [Row 0 to 9]

CD8. Record the rank number of the selected child: _

CD9. Write the name and line number of the child selected for the module from CD3 and CD2, based on the rank number in CD8.

____ Name
_ _ Line number

CD10. 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.

CD11. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

[] 1 Yes
[] 2 No

CD12. Explained why (name)'s behaviour was wrong.

[] 1 Yes
[] 2 No

CD13. Shook him/her.

[] 1 Yes
[] 2 No

CD14. Shouted, yelled at or screamed at him/her.

[] 1 Yes
[] 2 No

CD15. Gave him/her something else to do.

[] 1 Yes
[] 2 No

CD16. Spanked, hit or slapped him/her on the bottom with bare hand.

[] 1 Yes
[] 2 No

CD17. 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

CD18. Called him/her dumb, lazy, or another name like that.

[] 1 Yes
[] 2 No

CD19. Hit or slapped him/her on the face, head or ears.

[] 1 Yes
[] 2 No

CD20. Hit or slapped him/her on the hand, arm, or leg.

[] 1 Yes
[] 2 No

CD21. Beat him/her up, that is hit him/her over and over as hard as one could.

[] 1 Yes
[] 2 No

CD22. 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 Don't know/no opinion

Hand washing: HW

HW1. Please show me where members of your household most often wash their hands.

[] 1. Observed

Not observed
[] 2 Not in dwelling/plot/yard
[] 3 No permission to see
[] 6 Other reason

HW2. Observe presence of water at the specific 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. Record if soap or detergent is present at the specific place for handwashing.
Circle all that apply.
Skip to HH19 if any soap or detergent code (A, B, C or D) is circled. If "None" (Y) is circled, continue with HW4.

[] A Bar soap (Go to HH19)
[] B Detergent (powder/liquid/paste) (Go to HH19)
[] C Liquid soap (Go to HH19)
[] D Ash/mud/sand (Go to HH19)
[] Y None

HW4. Do you have any soap or detergent (or other locally used cleansing agent) in your household for washing hands?

[] 1 Yes
[] 2 No (Go to HH19)

HW5. Can you please show it to me?
Record observation. Circle all that apply.

[] A Bar soap
[] B Detergent (powder/liquid/paste)
[] C Liquid soap
[] D Ash/mud/sand
[] Y Not able/does not want to show

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
[] 6 No salt in the house
[] 7 Salt not tested

HH20. Thank the respondent for his/her cooperation and check the Household Listing Form:

[] A separate Questionnaire for Individual Women has been issued for each woman age 15-49 years in the household list (HL7)

[] A separate Questionnaire for Individual Men has been issued for each man age 15-49 years in the household list (HL7A)

[] A separate Questionnaire for Children Under Five has been issued for each child under age 5 years in the household list (HL9)

Return to the cover page and make sure that all information is entered, including the number of eligible women (HH12), under-5s (HH14) and men (HH13A).
Make arrangements for the administration of the remaining questionnaire(s) in this household.

Interviewer's observations ________

Field editor's observations ________