MICS Household Questionnaire
[UNICEF Version: 22 October 2013]
Name of survey
Household Information Panel: HH
HH1. Cluster number: _ _ _
HH2. Household number: _ _
HH3. Interviewer name and number
Name ____
Number _ _
Number _ _
HH4. Supervisor name and number:
Name ____
Number _ _
Number _ _
HH5. Day/month/year of interview
_ _ / _ _ /201 _
HH6. Area
[] 1 Urban
[] 2 Rural
[] 2 Rural
HH7. Region
[] 1 Region 1
[] 2 Region 2
[] 3 Region 3
[] 4 Region 4
[] 5 Region 5
[] 6 Region 6
[] 2 Region 2
[] 3 Region 3
[] 4 Region 4
[] 5 Region 5
[] 6 Region 6
HH8. Is the household selected for questionnaire for men?
[] 1 Yes
[] 2 No
[] 2 No
We are from (country-specific affiliation). 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 (insert number) 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 (Complete HH9. Discuss this result with your supervisor.)
[] No, permission is not given (Complete 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:
If the household is selected for Questionnaire for Men
HH13A. Number of men age 15-49 years: (if household is selected for questionnaire for men):_ _
After all questionnaires for the household have been completed, fill in the following information:
HH13B. Number of men'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
_ _ Minuets
_ _ Minuets
List of Household Members: 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
[] 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. Did (name) stay here last night
[] 1 Yes
[] 2 No
[] 2 No
HL7A. Circle line no. If man age 15-49 and the house-hold is selected for Questionnaire for men.
HL7B. Circle line no. If children 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 and go to HL13. If "No", record 00.
HL12A. Where does (name)'s natural mother live?
[] 1 In another household in this country
[] 2 Institution in this country
[] 3 Abroad
[] 8 DK
[] 2 Institution in this country
[] 3 Abroad
[] 8 DK
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 and go to HL15. If "No", record 00.
HL14A. Where does (name)'s natural father live?
[] 1 In another household in this country
[] 2 Institution in this country
[] 3 Abroad
[] 4 DK
[] 2 Institution in this country
[] 3 Abroad
[] 4 DK
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 [After HL1 to HL4 questions]
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 Servant (live-in)
[] 96 Other (not related)
[] 98 DK
[] 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 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 school (name) has ever attended?
For household members age 5 and above. If level=0, skip to ED5
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK
[] 1 Primary
[] 2 Secondary
[] 3 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 2013-2014, 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
[] 2 Secondary
[] 3 Higher
[] 8 DK
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK
Grade:
_ _
[] 98 DK
[] 98 DK
ED7. During the previous school year, that is 2012-2013, 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 skip to ED7
Level:
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 8 DK
Grade:
_ _
[] 98. DK
[] 98. DK
Selection of One Child For Child Labour/Child Discipline: SL
SL1. Check HL6 in the list of household members and write the total number of children age 1-17 years.
Total number: _
SL2. Check the number of children age 1-17 years in SL1:
[] Zero (Go to household characteristics module.)
[] One (Go to SL9 and record the rank number as "1", enter the line number, child's name and age.)
[] Two or more (Continue with SL2A.)
[] One (Go to SL9 and record the rank number as "1", enter the line number, child's name and age.)
[] Two or more (Continue with SL2A.)
SL2A. List each of the children age 1-17 years below in the order they appear in the List of household members. Do not include other household members outside of the age range 1-17 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 1-17 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 Labor: CL
CL1. Check selected child's age from SL9:
[] 1-4 years (Go to next module)
[] 5-17 years (Continue with CL2)
[] 5-17 years (Continue with CL2)
CL2. Now I would like to ask about any work children in this household may do.
Since last (day of the week), did (name) do any of the following activities, even for only one hour?
A. Did (name) do any work or help on his/her own or the household's plot/farm/food garden or looked after animals? For example, growing farm produce, harvesting, or feeding, grazing, milking animals?
[] 1 Yes
[] 2 No
[] 2 No
B. Did (name) help in family business or relative's business with or without pay, or run his/her own business?
[] 1 Yes
[] 2 No
[] 2 No
C. Did (name) produce or sell articles, handicrafts, clothes, food or agricultural products?
[] 1 Yes
[] 2 No
[] 2 No
D. Since last (day of the week), did (name) engage in any other activity in return for income in cash or in kind, even for only one hour?
If "No", Probe: Please include any activity (name) performed as a regular or casual employee, self-employed or employer; or as an unpaid family worker helping out in household business or farm.
[] 1 Yes
[] 2 No
[] 2 No
CL3. Check CL2, A to D
[] There is at least one "yes" (Continue with CL4)
[] All answers are "No" (Go to CL8)
[] All answers are "No" (Go to CL8)
CL4. Since last (day of the week) about how many hours did (name) engage in this activity/these activities, in total?
If less than one hour, record "00"
Number of hours: _ _
CL5. Does the activity/do these activities require carrying heavy loads?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
CL6. Does the activity/do these activities require working with dangerous tools (knives etc.) or operating heavy machinery?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
CL7. How would you describe the work environment of (name)?
[A] Is (name) exposed to dust, fumes or gas?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[B] Is (name) exposed to extreme cold, heat or humidity?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[C] Is (name) exposed to loud noise or vibration?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[D] Is (name) required to work at heights?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[E] Is (name) required to work with chemicals (pesticides, glues, etc.) or explosives?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[F] Is (name) exposed to other things, processes or conditions bad for (name)'s health or safety?
[] 1 Yes
[] 2 No
[] 2 No
CL8. Since last (day of the week), did (name) fetch water or collect firewood for household use?
[] 1 Yes
[] 2 No (Go to CL10)
[] 2 No (Go to CL10)
CL9. In total, how many hours did (name) spend on fetching water or collecting firewood for household use, since last (day of the week)?
If less than one hour, record "00"
Number of hours: _ _
CL10. Since last (day of the week), did (name) do any of the following for this household?
[A] Shopping for household?
[] 1 Yes
[] 2 No
[] 2 No
[B] Repair any household equipment?
[] 1 Yes
[] 2 No
[] 2 No
[C] Cooking or cleaning utensils or the house?
[] 1 Yes
[] 2 No
[] 2 No
[D] Washing clothes?
[] 1 Yes
[] 2 No
[] 2 No
[E] Caring for children?
[] 1 Yes
[] 2 No
[] 2 No
[F] Caring for the old or sick?
[] 1 Yes
[] 2 No
[] 2 No
[G] Other household tasks?
[] 1 Yes
[] 2 No
[] 2 No
CL11 Check CL10, A to G
[] There is at least one "yes" (Continue with CL12)
[] All answers are "no" (Go to next module)
[] All answers are "no" (Go to next module)
CL12. Since last (day of the week), about how many hours did (name) engage in this activity/these activities, in total?
If less than one hour, record "00"
Number of hours: _ _
Child Discipline: CD
CD1. Check selected child's age from SL9
[] 1-14 years (Continue with CD2)
[] 15-17 years (Go to next module)
[] 15-17 years (Go to next module)
CD2. Write the line number and name of the child from SL9.
Line number: _ _
Name: ____
Name: ____
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
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
[] 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) ____
[] 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) ____
[] 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 the dwelling floor.
Record observation.
Natural floor
[] 11 Earth/sand
[] 12 Dung
[] 12 Dung
Rudimentary floor
[] 21 Wood planks
[] 22 Palm/bamboo
[] 22 Palm/bamboo
Finished floor
[] 31 Parquet or polished wood
[] 32 Vinyl or asphalt strips
[] 33 Ceramic tiles
[] 34 Cement
[] 35 Carpet
[] 32 Vinyl or asphalt strips
[] 33 Ceramic tiles
[] 34 Cement
[] 35 Carpet
[] 96. Other (specify) ____
HC4. Main material of the roof.
Record observation.
Natural roofing
[] 11 No roof
[] 12 Thatch/palm leaf
[] 13 Sod
[] 12 Thatch/palm leaf
[] 13 Sod
Rudimentary roofing
[] 21 Rustic mat
[] 22 Palm/bamboo
[] 23 Wood planks
[] 24 Cardboard
[] 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) ____
[] 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 observation
Natural walls
[] 11 No walls
[] 12 Cane/palm/trunks
[] 13 Dirt
[] 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
[] 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
[] 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) ____
[] 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
[] 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] Country specific items (Add as necessary)
[] 1 Yes
[] 2 No
[] 2 No
HC9. Does any member of your household own:
[A] A watch?
[] 1 Yes
[] 2 No
[] 2 No
[B] A mobile telephone?
[] 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
[G] A boat with a motor?
[] 1. Yes
[] 2. No
[] 2. No
[H] Country specific items (Add as necessary)
[] 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 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)
[] 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: _ _
[G] Country specific additions (Add as necessary)
Numbers: _ _
HC15. Does any member of this household have a bank account?
[] 1. Yes
[] 2. No
[] 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)
[] 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).
TN4. Mosquito net observed?
[Ask up to 3 Nets]
[] 1 Observed
[] 2 Not 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
[] 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
[] 22 Brand E
[] 23 Brand F
[] 26 Other (specify) ____
[] 28 DK brand
[] 36. Other type (specify) ____
[] 98. DK Brand/type
[] 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 months ago
[] 98 DK/not sure
[] 95 More than 36 months 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 with next question)
[] Pre-treated (21-28) (Go to TN9)
[] Else (Continue with next question)
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
[] 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 mosquitos?
[] 1 Yes
[] 2 No (Go to TN11)
[] 8 DK/not sure (Go to TN11)
[] 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 months ago
[] 98 DK/not sure
[] 95 More than 24 months 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)
[] 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
_ _ 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 questionnaire 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 (Go to next module)
[] 2 No (Go to next module)
[] 8 DK (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
[] B Private company
[] C Non-governmental organization
[] X Other (specify) ____
[] Z DK
Water and Sanitation: WS
WS1. What is the main source of drinking water used by 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 neighbour (Go to WS6)
[] 14 Public tap/standpipe (Go to WS3)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped into 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 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)
[] 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 neighbour (Go to WS6)
[] 14 Public tap/standpipe
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped into 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 collector
[] 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
[] 2 No (Go to WS8)
[] 8 DK
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, 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
[] 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 (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 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) ____
[] 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)
[] 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 where members of this household 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
[] 3 No permission to see
[] 6 Other reason (specify) ____
[] 3 No permission to see
[] 6 Other reason (specify) ____
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, detergent or ash/mud/sand 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)
[] D Ash/mud/sand (Go to HH19)
[] B Detergent (powder/liquid/paste) (Go to HH19)
[] C Liquid soap (Go to HH19)
[] D Ash/mud/sand (Go to HH19)
HW4 Do you have any soap or detergent or ash/mud/sand 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
[] D Ash/mud/sand
[] B Detergent (powder/liquid/paste)
[] C Liquid soap
[] D Ash/mud/sand
HH19. Record the time
Hours 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).
Check HH8. If the household is selected for questionnaire for individual men:[] A separate questionnaire for individual men has been issued for each man age 15-49 years in the list of household members (HL7A).
[] 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), men (HH13A), 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 ________