Appendix F: Questionnaires
National Office of Statistics "ONS"
MICS household questionnaire
We are from the National Office of Statistics. We are working on a project concerned with mother and child's health and certain household characteristics. I would like to talk to you about these subjects. The interview will take about 30 minutes. All the information we obtain will remain strictly confidential and your answers will never be divulged. 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.
Household Information Panel: HH
HH1. Region ("wilaya"): _ _ _
HH2. Department ("moughataa") _ _ _
HH3.Commune: ______
HH4. Locality: ______
HH5. DR: ______
HH6: Cluster: ______
HH7. Area:
[] 1 Urban
[] 2 Rural
[] 2 Rural
HH8. Household number: ______
HH9. Name of Head of household: ______
HH10: Interviewer name and number: ______
HH11. Field editor name and number: ______
HH12. Date of interview: ______
After all questionnaires for the household have been completed, fill in the following information:
HH13. Result of HH interview:
[] 1 Completed
[] 2 Not at home
[] 3 Refused
[] 4 HH not found/destroyed
[] 6 Other (specify) ____
[] 2 Not at home
[] 3 Refused
[] 4 HH not found/destroyed
[] 6 Other (specify) ____
HH14. Respondent to HH questionnaire
Name: ____
Line No: _ _
Line No: _ _
HH11. Total number of household members: _ _
HH15. No. of women eligible _ _
HH16. No. of women questionnaires completed: _ _
HH17. No. of children under age 5: _ _
HH18. No. of under-5 questionnaires completed: _ _
HH19: No. of men eligible: ______
HH20. No. of men questionnaires completed: ______
HH21. Number of visits:
1 Date ______
2 Date ______
3 Date ______
HH22. Data entry clerk name and no.: ______
Observations: ______
Household listing form
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 another sheet if there are more than 15 household members.
[] Tick here if another sheet is used
HL1. Line no.: _ _
HL2. Name: ____
HL3. What is the relationship of (name) to the head of the household?
[] 01 Head
[] 02 Wife or husband
[] 03 Son or daughter
[] 04 Son-in-law/ daughter in-law
[] 05 Grandson/granddaughter
[] 06 Mother/Father
[] 07 Father-in-law/Mother-in-law/Brother-in-law/Sister-in-law
[] 08 Brother / sister
[] 09 Uncle/aunt
[] 10 Niece/nephew by blood
[] 11 Other relative
[] 12 Adopted/foster/stepchild
[] 13 Not Related
[] 98 Don't know
[] 02 Wife or husband
[] 03 Son or daughter
[] 04 Son-in-law/ daughter in-law
[] 05 Grandson/granddaughter
[] 06 Mother/Father
[] 07 Father-in-law/Mother-in-law/Brother-in-law/Sister-in-law
[] 08 Brother / sister
[] 09 Uncle/aunt
[] 10 Niece/nephew by blood
[] 11 Other relative
[] 12 Adopted/foster/stepchild
[] 13 Not Related
[] 98 Don't know
HL4. Is (name) male or female?
[] 1 Male
[] 2 Female
[] 2 Female
HL5. How old is (name)? How old was (name) on his/her last birthday?
Record in Completed years
Age: _ _
[] 98 DK
[] 98 DK
HL6. Eligible for women's interview
_ _Circle line no. if woman is age 15-49
HL7. Eligible for child labour module
For each child age 5-14: Who is the mother or primary caretaker of this child?
_ _ Record line no. of mother/caretaker
HL8. Eligible for under-5 interview
For each child under 5: Who is the mother or primary caretaker of this child
_ _ Record line no. of mother/caretaker
HL8A. Eligible for men's interview
_ _Circle line no. if man is age 15-59
For children age 0-17 years ask HL9-HL12
HL9. Is (name's) biological mother alive?
[] 1 Yes
[] 2 No (Go to HL11)
[] 8 DK (Go to HL11)
[] 2 No (Go to HL11)
[] 8 DK (Go to HL11)
HL10. If alive: Does (name's) biological mother live in this household?
_ _ Record line no. of mother or 00 for 'no'
HL11. Is (name's) biological father alive?
[] 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)
HL12. If alive: Does (name's) biological father live in this household?
_ _ Record line no. of father or 00 for 'no'
Are there any other persons living here - even if they are not members of your family or do not have relatives living in this household?
Including children at work or at school? If yes, insert child's name and complete household form.
Then, complete the totals above.
Totals
_ _ Women 15-49
_ _ Children 5-14
_ _ Under-5s
_ _ Men 15-59
_ _ Children 5-14
_ _ Under-5s
_ _ Men 15-59
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; do the same for each man age 15-59. 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, each eligible man, and each child under five in the household.
Education Module: ED
For household members age 5 and above
ED1. Line no. _ _
ED1A. Name ____
ED2. Has (name) ever attended any formal or informal school or preschool?
[] 1 Yes (Go to ED3)
[] 2 No (Go to next line)
[] 8 DK (Go to next line)
[] 2 No (Go to next line)
[] 8 DK (Go to next line)
ED3. What is the highest level of school (name) attended? What is the highest grade (name) completed at this level?
Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 University
[] 5 Quranic School
[] 6 Bedouin Nomadic School "Mahadra"
[] 8 DK
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 University
[] 5 Quranic School
[] 6 Bedouin Nomadic School "Mahadra"
[] 8 DK
Grade: _ _
[] 98 DK
If less than 1 grade, enter 00.
[] 98 DK
If less than 1 grade, enter 00.
For household members age 5-24 years
ED4. During the (2006-2007) school year, did (name) attend formal or informal school at any time?
[] 1 Yes
[] 2 No (Go to ED7)
[] 8 DK (Go to ED7)
[] 2 No (Go to ED7)
[] 8 DK (Go to ED7)
ED5. Since last (day of the week), how many days did (name) attend school?
Insert number of days in space below. Record 9 if last week was a vacation week.
Days ______
Days ______
ED6. During this/that school year, which level and grade is/was (name) attending?
Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 University
[] 5 Quranic School
[] 6 Bedouin Nomadic School "Mahadra"
[] 8 DK
Grade: _ _
[] 98 DK
[] 0 Pre-school
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 University
[] 5 Quranic School
[] 6 Bedouin Nomadic School "Mahadra"
[] 8 DK
Grade: _ _
[] 98 DK
ED7. Did (name) attend school or preschool at any time during the previous school year, that is 2005-2006?
[] 1 Yes
[] 2 No (Go to next line)
[] 8 No (Go to next line)
[] 2 No (Go to next line)
[] 8 No (Go to next line)
ED8. During that previous school year, which level and grade did (name) attend?
Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 University
[] 5 Quranic School
[] 6 Bedouin Nomadic School "Mahadra"
[] 8 DK
Grade: _ _
[] 98 DK
[] 0 Pre-school
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 University
[] 5 Quranic School
[] 6 Bedouin Nomadic School "Mahadra"
[] 8 DK
Grade: _ _
[] 98 DK
Water and sanitation module: WS
WS1. What is the main source of drinking water for members of your household?
Piped water
[] 11 Piped into dwelling (Go to WS5)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe (Go to WS3)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe (Go to WS3)
[] 21 Tubewell/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 (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 WS5)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe
[] 21 Tubewell/borehole
Dug well
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
[] 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. How long does it take to go there, get water, and come back?
_ _ _ No. of minutes
[] 995 Water on premises (Go to WS5)
[] 998 DK
[] 995 Water on premises (Go to WS5)
[] 998 DK
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.
[] 1 Adult woman
[] 2 Adult man
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK
[] 2 Adult man
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK
WS5. Do you treat your water in any way to make it safer to drink?
[] 1 Yes
[] 2 No (Go to WS7)
[] 8 DK (Go to WS7)
[] 2 No (Go to WS7)
[] 8 DK (Go to WS7)
WS6. What do you usually do to the water to make it safer to drink?
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
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.
Flush/pour flush
[] 11 Flush to piped sewer system
[] 12 Flush to septic tank
[] 13 Flush to somewhere else
[] 15 Flush to unknown place/not sure/DK where
[] 12 Flush to septic tank
[] 13 Flush to somewhere else
[] 15 Flush to unknown place/not sure/DK where
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Covered latrines
[] 23 Pit latrine / open pit
[] 95 No facilities or bush or field (Go to next module)
[] 96 Other (specify) ____
[] 22 Covered latrines
[] 23 Pit latrine / open pit
[] 95 No facilities or bush or field (Go to next module)
[] 96 Other (specify) ____
WS8. Do you share this facility with other households?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
WS9. How many households in total use this toilet facility
0_ No. of households (if less than 10)
[] 10 Ten or more households
[] 98 DK
[] 10 Ten or more households
[] 98 DK
WS10. Is there soap in the latrine?
[] 1 Yes
[] 2 No
[] 2 No