Household Information Panel: HH

Province: _ _ _

District _ _ _

Administrative office: _ _ _

District _ _ _

Urban/rural

Location name (specific neighborhood) _ _ _

Name of the enumeration area _ _ _

Household Number _ _ _

Name of head of household: ____

Language used in the interview

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

HH3. Interviewer name and number:

Result of HH interview:

Total number of visits _ _

Respondent to HH questionnaire

HH11. Total number of household members: _ _

HH12. No. of women eligible for interview: _ _

HH13. No. of women questionnaires completed: _ _

HH14. No. of children under age 5: _ _

HH15. No. of under-5 questionnaires completed: _ _

Interviewer/supervisor notes: Use this space to record notes about the interview with this household, such as call-back times, incomplete individual interview forms, number of attempts to re-visit, etc.

HH16. Data entry clerk: _ _

Household listing form: 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? (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 are more than 15 household members.
[] Tick here if continuation sheet used

HL1. Line no.: _ _

HL2. Name (Please tell me the names of the people who normally live
in this house, starting with the head of the household): ____

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
HL5A. what is the marital status of (Name)? Ask for people who are 12 years old or more

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. (Name) were you very ill during at least 3 of the last 12 months?

Survival of parents and residence of people under 25 years old. Ask HL9-HL12a

HL9. Is (name's) natural mother alive?

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

HL10A. If there is no answer to HL8A or HL10 was marked "00", ask: Was she very ill during at least 3 of the last 12 months?

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

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

HL12A. If there is no answer to HL8A or HL12was marked "00", ask: Was she very ill during at least 3 of the last 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

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.
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 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 school or preschool?

ED2A. (Name) how old were you when you started attending school?

ED3. What is the highest level of school (name) attended? What is the highest grade (name) completed at this level? If it was Technical Education what is the highest year that (name) completed at this level?

For household members age 5-24 years

ED3a. (Name) have you ever repeated a grade/year?

ED3b. If yes: how many times did (Name) repeat?

ED4. During the 2008 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 grade is/was (name) attending?

ED7. Did (name) attend school or preschool at any time during the previous school year, that is 2007?

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

ED8a. Check, ED3. Has (name) completed primary education?

ED8b. Does (name) know how to read or write?

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.
ED6A. Do you have a bathroom in your house?

ED6B. Do you use a nearby bathroom?

WS7. The bathroom you use has
If "flush" or "pour flush", probe: Where does it flush to?
If necessary, ask permission to observe the facility

WS7A. Do you treat your water in any way to make it safer to drink?

WS8. Do you share this facility with other households?

WS9. How many households, in all, use this bathroom?

WS9A. Where do you exercise?

Household characteristics module: HC

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

HC1B. What is the mother tongue/native language of the head of this household?

HC2a. How many rooms does the house have (without counting the kitchen and bathroom)?

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

Verify and note the characteristics of the building materials used in the house of the household. If in doubt, ask the household members.

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.
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:







HC10a. When was the last time you had a newspaper in the house?

HC11. Does any member of this household own any land that can be used for agriculture?
[This question is from optional modules]

HC12. How many hectares of agricultural land do members of this household own?
[This question is from optional modules]
If more than 97, record '97'. If unknown, record '98'.
HC13. Does this household own any livestock, herds, or farm animals?
[This question is from optional modules]
HC14. How many of the following animals does this household have?
[This question is from optional modules]






HC15A. Do you or someone in this household own this dwelling, or do you rent this dwelling?

HC15B. Do you or someone in this household have a title deed for this dwelling?

Mosquito nets and spraying module

TN1. Does your household have any mosquito nets that can be used for sleeping under?

TN2. How many mosquito nets does your household have? If they have seven or more, write '7'.

TN2A. Were the inside walls of your house sprayed against mosquitoes at any time in
the last 12 months?

TN2B . How many months ago was it sprayed?

TN2C. Who sprayed?

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? _ _

Disability: DA

To be asked of the mother/father or other person looking after all the children aged 2--17 years who live in the household. For those under 2 or over 17 years old, strike though with a horizontal line. Now i would like to ask if any child in this household aged 2--17 years has any of the health condition that I will mention.

DA1. Line no.

DA2. Child's name

DA3. Compared with other children, does or did (name) have any serious delay in sitting, standing, or walking?

DA4. Compared with other children, does (name) have difficulty seeing, either in the daytime or at night?

DA5. Does (name) appear to have difficulty hearing? (uses hearing aid, hears with difficulty, completely deaf?)

DA6. When you tell (name) to do something, does he/she seem to understand what you are saying?

DA7. Does (name) have difficulty in walking or moving his/her arms or does he/she have weakness and/or stiffness in the arms or legs?

DA7A. (Name) does he/she suffer from the following disabilities?

DA8. Does (name) sometimes have fits, become rigid, or lose consciousness? (if more than 9 years old)

DA9. Does (name) learn to do things like other children his/her age?

DA10. Does (name) speak at all (can he/she make him or herself understood in words; can say any recognizable words)?

DA11. (For 3-9 year olds): Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?

DA12. (For 2-year-olds): Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?

DA13. Compared with other children of the same age, does (name) appear in any way mentally backward, dull or slow?

Orphan-hood Module

OV2. Has any usual member of your household died in the past 12 months? If the answer is no, ask : did any baby who cried or showed any sign of life survive only a few hours or days?

OV3. Give the name, age and sex of all the people who have died in this period.

OV4. Of those who died in this period, was anyone between 18 and 59 years old
seriously ill in 3 of the last 12 months before he/she died?

OV4A. Verify HL5 and OV4.

OV5. Return to the Household listing and check the following:

OV8A. List below all children aged 0--17 years. Register the names, line numbers and ages of all the children, starting with the first child and continuing in the order in which they appear in the household listing module. use a continuation questionnaire of there are more than four children aged 0--17 years in the household. After listing all the children, continue with OV9. ask all the questions for one child before passing to the next child..
OV8B. 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 OV218 are for all the children listed in OV8]
OV9. I 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 OV8C: 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?

Income module

OV19. Did your household receive any support from the Food Subsidy Programme (PSA) in
the last 12 months?

OV20. Did your household receive any material support from the Direct Social Support
Programme (PASD) in the last 12 months?

Insecticide-treated mosquito nets

TN1. In your household, do you have mosquito netting you can use for sleeping?

TN2. How many mosquito nets do you have in your household? If more than 7, record 7.

TN2. How many mosquito nets do you use for sleeping? If more than 7, record 7.

TN3. Is the mosquito net (regardless of which one) one of the following brands?
Read the name of each brand, show an image, and circle the codes Yes or No for each brand. If possible, ask the respondent to show you the net to double check the brand.
Permanent mosquito netting:

Other mosquito nets:

TN3A. Where did you get the (name of net highest in the list of nets available in the household, in TN3) mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than one net in the same category, ask question referring to the most recently obtained net.
TN3B. How much did you pay for the (name of net highest in the list of nets available in the household, in TN3) mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than one net in the same category, ask question referring to the most recently obtained net.
TN4. Verify TN3 for the type of mosquito net(s). Check the corresponding box below and follow the instructions below:

TN5. When you acquired your newest mosquito net, was it treated with an insecticide to kill or repel mosquitos?

TN6. How long have you owned the most recently obtained mosquito net?
If less than one month, record '00.'
If the response is "12 months" or "1 year," probe to determine if the mosquito net was obtained exactly 12 months ago, earlier, or later.

TN7. Since you've had mosquito netting, have you treated them or dipped them in a liquid that kills or repels mosquitos?

TN8. How long has it been since the net was last soaked or dipped in insecticide?
If less than one month, record '00.'
If the response is "12 months" or "1 year," probe to determine if the mosquito net was obtained exactly 12 months ago, earlier, or later.

Salt iodization module: SI

SI1. What kind of salt do you use for cooking? Once you have examined the salt,
Circle number that corresponds to test outcome.

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

SI3. Does any child under the age of 5 reside in the household?
Check household listing, column HL8. You should have a questionnaire with the Information Panel filled in for each eligible child.
[] Yes (Go to questionnaire for children under five to administer the questionnaire 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.)