We are from National Bureau of Statistics, NIGERIA. We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will BE FOR A SHORT PERIOD. All the information we obtain will remain strictly confidential and your answers will never be identified. 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.
May I start now? If permission is given, begin the interview.

Household Information Panel: HH

HH1. EA Name_________
Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

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

HH6. Area??? Sector

HH7. State Name:_________

HH8. Name of head of household: ____

After all questionnaires for the household have been completed, fill in the following information:

HH9. Result of HH interview:

HH10. 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: _ _

HH16A. Time interview start: _:_
Time interview end: _:_

HH16B. Editor?s name____
Editor?s Number _ _

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 is not enough room in 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 5-17: 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. If age 18-59 years
Has (name) been very sick for least 3 months during the past 12 months?

For children age 0-17 years ask HL9-HL12A

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 the household: Has (name?s) mother been very sick for at least 3 months in 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 the household: 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

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?

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 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 (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?

Household characteristics module: HC

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

HC1B. Mother tongue of head

HC1C. Ethnic group of head

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, a closed stove, gas cooker and electric cooker?
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:







ST1. Do you feel secure from eviction from this dwelling?

Insecticide Treated Nets: TN

TN1. Does your household have any insecticide treated mosquito nets that can be used while sleeping?

TN2. How many insecticide treated mosquito nets does your household have?
If 7 or more nets, record '7'.
TN3. Is the insecticide treated net, any of the following type?
Read each type, show picture card, and circle codes for yes or no for each type. If possible, observe the net to verify type.
TN4. Check TN3 for type of net(s). Go through the above list in order until one box is checked and follow instructions:
TN5. When you got the (most recent) insecticide treated net, was it already treated with an insecticide to kill or repel mosquitoes?

TN6. How many months ago was the (most recent) insecticide treated 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 insecticide treated 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, record '00'. If answer is "12 months" or "1 year", probe to determine if net was treated exactly 12 months ago or earlier or later.
Children Orphaned and Made Vulnerable by HIV/AIDS: OV

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 these people between the ages of 18 and 59?

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

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

OV8. List all children aged 0-17 below. Record names, 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 OV18 are for all the children listed in OV8]
OV9. I would like to ask you about any formal, organized help or support that your household 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.

If no go to the next module.

OV10. Now I would like to ask you about the support your household received for (Name).
In the last 12 months, has your household received any medical support for (Name), such as
medical care, supplies or medicine?

OV11. In the last 12 months, has your household 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 household receive any of this support in the past 3 months?

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

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

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

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

OV17. Check OV8 for age of child:
OV18. In the last 12 months, has your household received any support for (name's) schooling, such as allowance, free admission, books or supplies?

Child labour module: CL

To be administered to mother/caretaker of each child in the household age 5 through 17 years. For household members below age 5 or above age 17, 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?
If more than one job, include all hours at all jobs.

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?

Maternal mortality module: MM

Administer to each adult household member. Copy name and line number of each adult (age 15 or over) in the household. If one of these adults is not at home, another adult may respond for him/her. Indicate this by placing a '1' in MM3, and insert line number of proxy respondent in MM4. For household members below age 15, leave rows blank

MM1. Line no.

MM2. Name

MM3. Is this a proxy report?

MM4. Line no. of proxy respondent (from household listing HL1)

MM5. How many sisters (born to the same mother) have you ever had?
If 00 go to the next line

MM6. How many of these sisters ever reached age 15?
If 00 go to the next line

MM7. How many of these sisters (who are at least 15 years old) are alive now?

MM8. How many of these sisters who reached age 15 or more have died?
If 00 go to the next line

MM9. How many of these dead sisters died while pregnant, or during childbirth, or during the six weeks after the end of pregnancy?

Salt iodization module: SI

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.

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, and 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, and administer the questionnaire to 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.)