Appendix F: Questionnaires

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:

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:

HH14. Respondent to HH questionnaire

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?

HL4. Is (name) male or female?

HL5. How old is (name)? How old was (name) on his/her last birthday?
Record in Completed years
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

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?

HL10. If alive: Does (name's) biological mother live in this household?

HL11. Is (name's) biological father alive?

HL12. If alive: Does (name's) biological 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 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

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?

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 (2006-2007) school year, did (name) attend formal or informal school 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 2005-2006?

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

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.
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

WS10. Is there soap in the latrine?