MICS household questionnaire
Household Information Panel: HH
HH0. District Number _ _ _
HH1. Cluster number: _ _ _
HH2. Household Number _ _ _
HH3. Enumerator name and number:
Name: ____
Number: _ _
Number: _ _
HH4. Supervisor name and number:
Name: ____
Number: _ _
Number: _ _
HH5. Day/month/year of interview _ _ / _ _ / _ _ _ _
HH6. Area:
[] 1 Urban
[] 2 Rural
[] 2 Rural
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:
[] 1 Completed
[] 2 Not at home
[] 3 Refused
[] 6 Other (specify) ____
[] 2 Not at home
[] 3 Refused
[] 6 Other (specify) ____
HH9. Respondent to HH questionnaire
Name: ____
Line No: _ _
Line No: _ _
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? _ _
[] 01 Yes
[] No
[] No
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?
[] 01 Head
[] 02 Wife or husband
[] 03 Son or daughter
[] 04 Son or daughter in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother or sister
[] 09 Brother or sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew by blood
[] 12 Niece/nephew by marriage
[] 13 Other relative
[] 14 Adopted/foster/stepchild
[] 15 Not Related
[] 98 Don't know
[] 02 Wife or husband
[] 03 Son or daughter
[] 04 Son or daughter in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother or sister
[] 09 Brother or sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew by blood
[] 12 Niece/nephew by marriage
[] 13 Other relative
[] 14 Adopted/foster/stepchild
[] 15 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) in his/her last birthday?
Record in Completed years
Age: _ _
[] 98 DK [See instructions: to be used only for elderly household members (code meaning "do not know/over age 50").]
[] 98 DK [See instructions: to be used only for elderly household members (code meaning "do not know/over age 50").]
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
HL8B. Eligible for men's interview
_ _Circle line no. if man is age 15-49
HL8A. If age 18-59
Has (Name) very sick been for at least 3 months during the past 12 month?
[] 1 Yes
[] 2 No
[] 8 DK
[] 1 Yes
[] 2 No
[] 8 DK
For children age 0-17 years ask HL9-HL12
HL9. Is (name's) natural 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) natural mother live in this household?
_ _ Record line no. of mother or 00 for 'no'
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?
[] 1 Yes
[] 2 No (Go to HL11)
[] 8 DK (Go to HL11)
[] 2 No (Go to HL11)
[] 8 DK (Go to HL11)
HL11. Is (name's) natural 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) natural father live in this household?
_ _ Record line no. of father or 00 for 'no'
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
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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
_ _ Women 15-49
_ _ Children 5-14
_ _ Under-5s
__ Men 15-49
_ _ Very Sick
_ _ Mother
_ _ Children 5-14
_ _ Under-5s
__ Men 15-49
_ _ Very Sick
_ _ Mother
Education Module: ED
For household members age 5 and above
ED1. Line no. _ _
ED1A. Name ____
ED1B. How old is (Name)? ____
How old was (Name) on his/her last birthday? ____
Record in completed years 98=DK
Record in completed years 98=DK
ED2. Has (name) ever attended school or preschool?
[] 1 Yes (Go to ED3)
[] 2 No (Go to next line)
[] 2 No (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 Secondary
[] 3 Higher
[] 6 Non-standard curriculum
[] 8 DK
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Non-standard curriculum
[] 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 (YEAR) school year, did (name) attend school or preschool at any time?
[] 1 Yes
[] 2 No (Go to ED7)
[] 2 No (Go to ED7)
ED5. Since last (day of the week), how many days did (name) attend school?
_ Insert number of days in space below
ED6. During this/that school year, which level and class is (name) attending?
Level:
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Non-standard curriculum
[] 8 DK
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Non-standard curriculum
[] 8 DK
Grade: _ _
[] 98 DK
[] 98 DK
ED7. Did (name) attend school or preschool at any time during the previous school year 2005?
[] 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?
Level:
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Non-standard curriculum
[] 8 DK
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Non-standard curriculum
[] 8 DK
Class: _ _
[] 98 DK
[] 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 WS4A)
[] 12 Piped into yard or plot (Go to WS4A)
[] 13 Public tap/standpipe (Go to WS3)
[] 12 Piped into yard or plot (Go to WS4A)
[] 13 Public tap/standpipe (Go to WS3)
[] 21 Tubewell/borehole with hand pump(Go to WS3)
[] 22 Tubewell/borehole with powered pump(Go to WS3)
Dug well
[] 22 Tubewell/borehole with powered pump(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 collection (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 collection
[] 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 WS4A)
[] 998 DK
[] 995 Water on premises (Go to WS4A)
[] 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?
[] 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
WS4A. How do you store water in the household?
[] 1 Jerry can/Narrow neck container with lid
[] 2 Jerry can/Narrow neck container without lid
[] 3 Open container with lid
[] 4 Open container without lid
[] 6 Others(specify) ____
[] 2 Jerry can/Narrow neck container without lid
[] 3 Open container with lid
[] 4 Open container without lid
[] 6 Others(specify) ____
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?
Ask for permission and 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
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab / open pit
[] 24 Pit latrine with slab and cover
[] 25 Pit latrine with slab and foot rest
[] 26 Pit latrine with slab, cover and foot rest
[] 31 Composting toilet
[] 41 Bucket
[] 51 Hanging toilet/hanging latrine
[] 95 No facilities or bush or field (Go to WS11)
[] 96 Other (specify) ____
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab / open pit
[] 24 Pit latrine with slab and cover
[] 25 Pit latrine with slab and foot rest
[] 26 Pit latrine with slab, cover and foot rest
[] 31 Composting toilet
[] 41 Bucket
[] 51 Hanging toilet/hanging latrine
[] 95 No facilities or bush or field (Go to WS11)
[] 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. Do have a hand-washing facility outside the toilet?
(Ask for permission and observe the facility.)
[] 1 Seen the facility filled with water
[] 2 Seen the facility but no water
[] 3 Not seen
[] 4 No facility
[] 2 Seen the facility but no water
[] 3 Not seen
[] 4 No facility
WS11. Does you HH have soap (or washing powder/liquid) at present?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
WS12. Can I see it? Ask them to show you
[] 1 Seen
[] 2 Not seen
[] 2 Not seen
Household characteristics module: HC
HC1A. What is the religion of the head of this household?
[] 1 Catholic
[] 2 CCAP
[] 3 Anglican
[] 4 Seventh Day Advent/Baptist
[] 5 Other Christian
[] 6 Muslim
[] 7 Hindu
[] 8 No religion
[] 96 Others (specify) ____
[] 2 CCAP
[] 3 Anglican
[] 4 Seventh Day Advent/Baptist
[] 5 Other Christian
[] 6 Muslim
[] 7 Hindu
[] 8 No religion
[] 96 Others (specify) ____
HC1B. What is your (household) tribe or ethnic group?
[] 1 Chewa
[] 2 Tumbuka
[] 3 Lomwe
[] 4 Tonga
[] 5 Yao
[] 6 Sena
[] 7 Nkonde
[] 8 Ngoni
[] 96 Others (specify) ____
[] 2 Tumbuka
[] 3 Lomwe
[] 4 Tonga
[] 5 Yao
[] 6 Sena
[] 7 Nkonde
[] 8 Ngoni
[] 96 Others (specify) ____
HC2. How many rooms in this household are used for sleeping?
No. 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
[] 22 Palm/bamboo
[] 23 Wood planks
Finished roofing
[] 31 Metal
[] 32 Wood
[] 33 Calamine/cement fiber
[] 34 Ceramic tiles
[] 35 Cement
[] 36 Roofing shingles
[] 32 Wood
[] 33 Calamine/cement fiber
[] 34 Ceramic tiles
[] 35 Cement
[] 36 Roofing shingles
[] 96 Other (specify) ____
HC5. Main material of the 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 Carton
[] 26 Reused wood
[] 22 Stone with mud
[] 23 Uncovered adobe
[] 24 Plywood
[] 25 Carton
[] 26 Reused wood
Finished walls
[] 31 Cement
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement blocks
[] 35 Covered adobe
[] 36 Wood planks/shingles
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement blocks
[] 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 Liquid propane gas (LPG) (Go to HC8)
[] 03 Natural gas (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 10 Animal dung
[] 11 Agricultural crop residue
[] 96 Other (specify) ____
[] 02 Liquid propane gas (LPG) (Go to HC8)
[] 03 Natural gas (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 10 Animal dung
[] 11 Agricultural crop residue
[] 96 Other (specify) ____
HC7. In this household, is food cooked on an open fire, an open stove or a closed stove?
Probe for type.
[] 1 Open fire
[] 2 Open stove
[] 3 Closed stove (Go to HC8)
[] 6 Other (specify) ____ (Go to HC8)
[] 2 Open stove
[] 3 Closed stove (Go to HC8)
[] 6 Other (specify) ____ (Go to HC8)
HC7A. Does the fire/stove have a chimney or a hood?
[] 1 Yes
[] 2 No
[] 2 No
HC8. Is the cooking usually done in the house, in a separate building, or outdoors?
[] 1 In the house
[] 2 In a separate building
[] 3 Outdoors
[] 6 Other (specify) ____
[] 2 In a separate building
[] 3 Outdoors
[] 6 Other (specify) ____
HC9. Does your household have:
Electricity?
[] 1 Yes
[] 2 No
[] 2 No
A radio?
[] 1 Yes
[] 2 No
[] 2 No
A television?
[] 1 Yes
[] 2 No
[] 2 No
A mobile telephone?
[] 1 Yes
[] 2 No
[] 2 No
A telephone (Landline)?
[] 1 Yes
[] 2 No
[] 2 No
A refrigerator?
[] 1 Yes
[] 2 No
[] 2 No
A computer?
[] 1 Yes
[] 2 No (Go to HC10)
[] 2 No (Go to HC10)
An internet connection?
[] 1 Yes
[] 2 No
[] 2 No
HC10. Does any member of your household own:
A watch?
[] 1 Yes
[] 2 No
[] 2 No
A bicycle?
[] 1 Yes
[] 2 No
[] 2 No
A motorcycle or scooter?
[] 1 Yes
[] 2 No
[] 2 No
An animal drawn cart?
[] 1 Yes
[] 2 No
[] 2 No
A car or truck?
[] 1 Yes
[] 2 No
[] 2 No
A boat with a motor?
[] 1 Yes
[] 2 No
[] 2 No
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 more than 97, record '97'. If unknown, record '98'.
Hectares _ _
HC13. Does this household own any livestock, herds, or farm animals?
[] 1 Yes
[] 2 No (Go to next module)
[] 2 No (Go to next module)
HC14. How many of the following animals does this household have?
If none, record '00'. If more than 97, record '97'. If unknown, record '98'.
Cattle?
Cattle _ _
Horses, donkeys, or mules?
Horses, donkeys, or mules _ _
Goats?
Goats _ _
Sheep?
Sheep _ _
Pigs?
Pigs _ _
Chickens?
Chickens _ _
ITN module
TN1. Does your HH have any mosquito net 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 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.
Public sector
[] 11 Govt. hospital
[] 12 Govt. health centre
[] 13 Govt. health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
[] 17 Village Health Committee
[] 12 Govt. health centre
[] 13 Govt. health post
[] 14 Village health worker
[] 15 Mobile/outreach clinic
[] 16 Other public (specify) ____
[] 17 Village Health Committee
Private medical sector
[] 21 Private hospital/clinic
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
[] 22 Private physician
[] 23 Private pharmacy
[] 24 Mobile clinic
[] 26 Other private medical (specify) ____
Other source
[] 31 Relative or friend
[] 32 Shop
[] 33 Traditional practitioner
[] 32 Shop
[] 33 Traditional practitioner
[] 96 Other (specify) ____
[] 98 DK
[] 98 DK
TN5. When you got the (most recent) 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
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.
[] Months ago __ __
[] 95 More than 24 months ago
[] 98 Not sure
[] 95 More than 24 months ago
[] 98 Not sure
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?
[] 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)
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.
[] Months ago __ __
[] 95 More than 24 months ago
[] 98 Not sure
[] 95 More than 24 months ago
[] 98 Not sure
Orphan-hood Module
OV1.Check HL5: any children 0-17?
[] Yes(Go to OV2)
[] No (Go to next module)
[] No (Go to next module)
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?
[] 1 Yes
[] 2 No (Go to OV5)
[] 2 No (Go to OV5)
OV3. (Of those who died in the past 12 months) were any of them people between the ages of 18 and 59 Yrs?
[] 1 Yes
[] 2 No (Go to OV5)
[] 2 No (Go to OV5)
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?
[] 1 Yes
[] 2 No (Go to OV5)
[] 2 No (Go to OV5)
OV5. Return to the Household listing and check the following:
Check total for HL9 and HL11.
[] At least one mother or father dead (Go to OV8)
[] No mother or father dead
[] No mother or father dead
Check totals for HL8A
[] At least one adult aged 18-59 very sick of last 12 months (Go to OV8)
[] No adult or aged 18-59 very sick of the last 12 months
[] No adult or aged 18-59 very sick of the last 12 months
Check total one HL10A and HL12A.
[] At least one mother or father ill 3 for the last 12 months (Go to OV8)
[] No mother or father ill 3 for the last 12 months ( Go to next module)
[] No mother or father ill 3 for the last 12 months ( Go to next module)
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?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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?
[] 1 Yes
[] 2 No (Go to OV13)
[] 8 DK
[] 2 No (Go to OV13)
[] 8 DK
OV12. Did your HH receive any of this support in the past 3 months?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
OV13. In the last 12 months, has your HH received any material support for (Name), such as
clothing, food or financial support?
[] 1 Yes
[] 2 No (Go to OV15)
[] 8 DK
[] 2 No (Go to OV15)
[] 8 DK
OV14. Did your HH receive any of this support in the past 3 months?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
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?
[] 1 Yes
[] 2 No (Go to OV17)
[] 8 DK
[] 2 No (Go to OV17)
[] 8 DK
OV16. Did your HH receive any of this support in the past 3 months?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
OV17. Check OV8: Age of the child 5-17 yr?
[] 1 Yes
[] 2 No
[] 2 No
OV18. In the last 12 months, has your HH received any support for (name's) schooling, such
as allowance, free admission, books or supplies?
[] 1 Yes
[] 2 No
[] 8 DK
[] 2 No
[] 8 DK
OV19. Check HL3:
[] 1 Yes (Go to OV20)
[] 2 No (Go to Next Child)
[] 2 No (Go to Next Child)
OV20. Length of stay of the child in this HH (Record in months):
[] Months __ __ __
OV20a. No. of previous homes/institutes where the child stayed before coming to this HH
(Exclude his/her parents' home)
__ _
[] 8 DK
[] 8 DK
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?
[] 1 Yes, for pay (cash or kind)
[] 2 Yes, unpaid
[] 3 No (Go to CL5)
[] 2 Yes, unpaid
[] 3 No (Go to CL5)
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?
_ _ If more than one job, include all hours at all jobs.
Record response then (Go to CL6)
Record response then (Go to CL6)
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?
[] 1 Yes, for pay (cash or kind)
[] 2 Yes, unpaid
[] 3 No
[] 2 Yes, unpaid
[] 3 No
CL6. During the past week, did (name) help with household chores such as shopping, collecting firewood, cleaning, fetching water, or caring for children?
[] 1 Yes
[] 2 No (Go to CL8)
[] 2 No (Go to CL8)
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)
[] 1 Yes
[] 2 No (Go to next line)
[] 2 No (Go to next line)
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?
[] 1 Yes
[] 2 No (Go to SI1)
[] 2 No (Go to SI1)
SI1B. Where did you hear about iodized salt?
Radio
[] 1 Yes
[] 2 No
[] 2 No
Television
[] 1 Yes
[] 2 No
[] 2 No
News paper
[] 1 Yes
[] 2 No
[] 2 No
Poster
[] 1 Yes
[] 2 No
[] 2 No
Salt packet itself
[] 1 Yes
[] 2 No
[] 2 No
Clothing
[] 1 Yes
[] 2 No
[] 2 No
Drama
[] 1 Yes
[] 2 No
[] 2 No
Others (specify) ___
[] 1 Yes
[] 2 No
[] 2 No
SI1C. Where do you store salt at home?
[] 1 Container with lid
[] 2 Container without lid
[] 3 Same packet in which salt was bought
[] 4 Lying on a surface (open)
[] 5 Lying on a surface (covered)
[]6 Ohers (specify) ___
[] 2 Container without lid
[] 3 Same packet in which salt was bought
[] 4 Lying on a surface (open)
[] 5 Lying on a surface (covered)
[]6 Ohers (specify) ___
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.
[] 1 Not iodized
[] 2 Less than 15 PPM (Go to SI2)
[] 3 15 PPM or more PPM (Go to SI2)
[] 6 No salt at home PPM (Go to SI2)
[] 7 Salt not tested PPM (Go to SI2)
[] 2 Less than 15 PPM (Go to SI2)
[] 3 15 PPM or more PPM (Go to SI2)
[] 6 No salt at home PPM (Go to SI2)
[] 7 Salt not tested PPM (Go to SI2)
SI14. Check SI1A and SI1:
[] If 1 in both SI1A and SI1 Continue with SI5)
[] 2 Otherwise SI1 Go to S25)
[] 2 Otherwise SI1 Go to S25)
SI5. Test showed that this salt is not iodised. What is the main reason for not using the iodised salt by your HH?
[] 1 Too expensive
[] 2 Not available in the market
[] 3 Doesn't taste good
[] 4 Not considered necessary
[] 5 Did not know that salt is not iodised
[] 6 Others ____
[] 2 Not available in the market
[] 3 Doesn't taste good
[] 4 Not considered necessary
[] 5 Did not know that salt is not iodised
[] 6 Others ____
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?
Check HL8 OF household listing module. You should have a Form with the Under-Five Information Panel filled in for each eligible child.
[] Yes (Go to children under five to administer the form to mother or caretaker of the first eligible child.)
[] No (End the interview by thanking the respondent for his/her cooperation.
Gather together all questionnaires for this household and tally the number of interviews completed on the cover page.)
[] Yes (Go to children under five to administer the form to mother or caretaker of the first eligible child.)
[] No (End the interview by thanking the respondent for his/her cooperation.
Gather together all questionnaires for this household and tally the number of interviews completed on the cover page.)