Household Information Panel: HH

HH0. District Number _ _ _

HH1. Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Enumerator name and number:

HH4. Supervisor name and number:

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

HH6. Area:

HH7. Name of head of household (To be filled-in after completing HL
Module): ____

HH15C be filled-in after all questions for the HH have been completed

HH8. Result of HH interview:

HH9. Respondent to HH questionnaire

HH10. Total number of household members: _ _

HH11. No. of women 15-49 eligible for interview: _ _

HH12. No. of women 15-49 questionnaires completed: _ _

HH13. No. of children under age 5: _ _

HH14. No. of under-5 questionnaires completed: _ _

HH15A. No. of men 15-49 for interview: _ _

HH15B. Is this HH selected for the male interview? _ _

HH15C. No. of men 15-49 questionnaires completed: _ _

HH16. Data entry clerk Name and No.: _ _

Household listing form: HL

First, please tell me the name of each person who usually lives here, starting with the head of the HH.
List the head of the HH in line 01. List all HH members (HL2), their relationship to the HH 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 is not enough room on this page.
[] Tick here if continuation sheet 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) in 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

HL8B. Eligible for men's interview

HL8A. If age 18-59
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?

HL10A. If mother does not live in HH: (for 00 in HL10) (Name's) mother been very months in Has sick for at least 3 the past 12 months?

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

HL12. If alive: Does (name's) natural father live in this household?

HL12A. If father does not live in HH: (for 00 in HL12)
Has (Name's) father been very sick for at least 3 months in the past 12 months

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

Education Module: ED

For household members age 5 and above

ED1. Line no. _ _

ED1A. Name ____

ED1B. How old is (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 class is (name) attending?

ED7. Did (name) attend school or preschool at any time during the previous school year 2005?

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?

WS4A. How do you store water in the household?

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?
Ask for permission and observe the facility.

WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

WS10. Do have a hand-washing facility outside the toilet?
(Ask for permission and observe the facility.)
WS11. Does you HH have soap (or washing powder/liquid) at present?

WS12. Can I see it? Ask them to show you
Household characteristics module: HC

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

HC1B. What is your (household) tribe or ethnic group?

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

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:









HC10. Does any member of your household own:







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 more than 97, record '97'. 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?

ITN module

TN1. Does your HH have any mosquito net that can be used while sleeping?

TN2. How many mosquito nets does your HH have?
If 7 or more nets, record '7'
Number of nets ____

TN2A. Where did you get the mosquito net?
If there is more than one net in the same category, ask question referring to the most recently obtained net.
TN5. When you got the (most recent) net, was it already treated with an insecticide to kill or repel mosquitoes?

TN6. How many months ago was the (most recent) net obtained?
If less than 1 month ago, record '00'.
If answer is "12 months" or "1 year", probe to determine if net was obtained exactly 12 months
ago or earlier or later.
TN7. Since you got the net(s) has it (have any of these nets) ever been soaked or dipped in a liquid to kill/repel mosquitoes?

TN8. How long ago was the most recent soaking/dipping done?
If less than 1 month ago, record '00'.
If answer is "12 months" or "1 year", probe to determine if net was obtained exactly 12 months
ago or earlier or later.
Orphan-hood Module

OV1.Check HL5: any children 0-17?

OV2. I would like you to think back over the past 12 months. Has any usual member of your household died in the past 12 months?

OV3. (Of those who died in the past 12 months) were any of them people between the ages of 18 and 59 Yrs?

OV4. (Of those who died in the past 12 months and were people between the ages of 18 and 59 Yrs) were any of them people seriously ill for 3. Of the 12 months before he/she died?

OV5. Return to the Household listing and check the following:
Check total for HL9 and HL11.

Check totals for HL8A

Check total one HL10A and HL12A.

OV8. List all children aged 0-17 below. Record game, line numbers and ages of all children, beginning with the first child and continue in order in which listed in the household listing module. Use a continuation sheet if there are more than 4 children age 0-17 in the household. Ask all questions for one child before moving to the next child. .
1st child
Name (from HL2) ____
Line number (from HL1) __
Age (from HL5) __ __
2nd child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ __
3rd child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ __
4th child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ _____ _

[Questions OV9 to OV20A are for all the children listed in OV8]
OV9. would like to ask you about any formal, organized help or support that your HH may have received for (Name) and for which you did not have to pay. By formal organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community-based. Remember this should be support for which you did not pay.
OV10. Now I would like to ask you about the support your HH received for (Name).
In the last 12 months, has your HH received any medical support for (Name), such as
medical care, supplies or medicine?

OV11. In the last 12 months, has your HH received any emotional or psychological support for
(Name), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home?

OV12. Did your HH receive any of this support in the past 3 months?

OV13. In the last 12 months, has your HH received any material support for (Name), such as
clothing, food or financial support?

OV14. Did your HH receive any of this support in the past 3 months?

OV15. In the last 12 months, has your HH received any social support for (Name), such as help
in HH work, training for a caregiver, or legal services?

OV16. Did your HH receive any of this support in the past 3 months?

OV17. Check OV8: Age of the child 5-17 yr?

OV18. In the last 12 months, has your HH received any support for (name's) schooling, such
as allowance, free admission, books or supplies?

OV19. Check HL3:

OV20. Length of stay of the child in this HH (Record in months):

OV20a. No. of previous homes/institutes where the child stayed before coming to this HH
(Exclude his/her parents' home)

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? _ _

Salt iodization module: SI

SI1A. Did you hear about iodized salt?

SI1B. Where did you hear about iodized salt?
Radio

Television

News paper

Poster

Salt packet itself

Clothing

Drama

Others (specify) ___

SI1C. Where do you store salt at home?

SI1. We would like to check whether the salt used in your household is iodized. May I see a sample of the salt used to cook the main meal eaten by members of your household last night?
Once you have examined the salt,
Circle number that corresponds to test outcome.

SI14. Check SI1A and SI1:

SI5. Test showed that this salt is not iodised. What is the main reason for not using the iodised salt by your HH?

SI2. Does any eligible woman age 15-49 reside in the household?
Check HL6 of household listing module. You should have a form with the information panel filled in for each eligible woman.
[] Yes (Go to women 15-49 to administer the questionnaire to the first eligible woman)
[] No (Continue to SI3)

SI3. Does any child under the age of 5 reside in the household?