MICS household questionnaire

All information in this questionnaire is for purely statistical purposes only.
It is considered confidential in accordance with the Public Statistics Law of 2000.

HH1. Cluster number: _ _ _

PHH1. Questionnaire's serial number in sample _ _ _ _ _

PHH3. Building's address: _ _

PHH4. Locality: _ _ _ _ _ _

HH2. Household Number _ _ _

HH7. Governorate: _ _

HH8. Name of head of household: ____

PHH13. Building number: _ _ _

Interviewer: ask the member who will answer the questions:
May I start now?

[] 1 Yes
[] 2 No

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

HH9. Result of HH interview:

[] 01 Completed
[] 02 Not at home
[] 03 Refused
[] 4 HH not found/destroyed
[] 05 Partially completed
[] 07 Household travelled
[] 08 Household destroyed
[] 09 Information not available
[] 96 Other (specify) ____

HH10. Respondent to HH questionnaire:

Name: ____
Line No: _ _

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: _ _

PHH6. Number of persons 5-24 years: _ _

PHH7. Number of children 5-14 years: _ _

PHH8. Number of persons 60 years and older interviewed: _ _

PHH9. Number of youth 15-29 years: _ _

HH5. Visits' schedule
1st visit Day_ _ Month_ _ Start hour_: _ End hour_: _
2nd visit Day_ _ Month_ _ Start hour_: _ End hour_: _
3rd visit Day_ _ Month_ _ Start hour_: _ End hour_: _

PHH5. Total number of visits: _

HH3. Interviewer name and number:

Name: ____
Number: _ _ _ _ _

HH4. Supervisor name and number:

Name: ____
Number: _ _ _ _ _

HH16.
Editor's number: _ _ _ _ _
Editor's Name: ____

HH17.
Data entry clerk's number: _ _ _ _ _
Data entry clerk's name: ____

PHH11.
Encoder's number: _ _ _ _ _
Encoder's name: ____

PHH12.
Date of data entry_ _/ _ _ /_ _ _ _

[] Interviewer: Please check the box with X if an additional questionnaire has been used.

Section 1: Household Members Data: HL

HL1. Member's serial number.: _ _

HL2. Names of usual household members (three names)
Please, tell me the names of all persons who usually live in your household, including small children and infants, and starting with the household head
Name: ____

HL3. What is the relationship of (name) to the head of the household?

[] 01 Household head
[] 02 Spouse
[] 03 Son or daughter
[] 04 Father or mother
[] 05 Brother or sister
[] 06 Grandparent
[] 07 Grandson or granddaughter
[] 08 Son-in-law or daughter-in-law
[] 09 Other relative
[] 96 Other

HL4. Is (name) male or female?

[] 1 Male
[] 2 Female

HL5. What is (name)'s date of birth in day, month and year?
Interviewer: record this information from official documents whenever possible

Day: _ _
Month: _ _
Year: _ _ _ _

Don't know:
Record 98 in days digit
Record 98 in months digit
Record 9998 in years digit

HL6. Interviewer: How old is the (name)?
Calculate age from the date of birth in HL5 and record the result in complete years.
If date of birth is unknown, ask for age and record it.

Age: _ _
Record (00) if age less than 1 year
[] 95 and more record 95
[] 98 not applicable

HL7. Interviewer: circle the line no. of the current or ever-married women aged 54-15 years
(i.e. eligible women for interview)

_ _ Circle line no. if woman is age 15-54

HL8. Interviewer: record line number of mother/carer of child aged 5-14 years eligible for interview for this age group

_ _ Record line no. of mother/caretaker

HL9. Interviewer: Record line number of mother / carer of child under 5 years eligible for interview for this age group

_ _ Record line no. of mother/caretaker

HL10. Did (name) stay here last night?

[] 1 Yes
[] 2 No

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

[] 1 Yes
[] 2 No (Go to HL13)
[] 8 DK (Go to HL13)

HL12. Does (name)'s natural mother live in this household?

_ _ Record her line no. from HL1
Record (00) if the mother does not live in the household

HL13. Is (name's) natural father alive?

[] 1 Yes
[] 2 No (Go to PHL15)
[] 8 DK (Go to PHL15)

HL14. Interviewer Does (name)'s natural father live in this household?

_ _ Record his line no. from HL1
Record (00) if the father does not live in the household

PHL15. Is (name) a registered refugee, nonregistered refugee or non-refugee?

[] 1 Registered refugee
[] 2 Non-registered refugee
[] 3 Non-refugee

For persons aged 10 years or over
[Note: PHL19 to PHL25]

PHL19. Relation to labor force during the past week:

[] 1 Worked 1-14 hrs
[] 2 Worked 15 - 34 hrs
[] 3 Worked 35 hrs and more (does not work but wants to work / worked before)
[] [4 Looked for work last week
[] 5 Did not seek work because given up hope (does not work but wants to work/ never worked before)
[] 6 Looked for work last week
[] 7 Did not seek work because given up hope (does not work and does not want to work because____)
[] 8 Studying/ training
[] 9 Housekeeping
[] 10 Disability/ aging/ illness
[] 11 Has another source of income/ pension
[] 12 Other

PHL20. Main occupation:
Interviewer: ask this question to members who answer PHL19 question from 1-5
What kind of work is/was (name) doing in detail?

Employment Status:

1. Employer
2. Self employed
3. Waged employee
4. Unpaid family member

Occupation: _____
Code: _____

PHL21. Does (name) smoke?

[] 1 Yes, mostly cigarettes (Go to PHL23)
[] 2 Yes, mostly pipe (Go to PHL24)
[] 3 Yes, mostly narghile(Go to PHL24)
[] 4 Yes, cigarettes and narghile (Go to PHL23)
[] 5 Smoked in the past and quit smoking(Go to PHL22)
[] 6 Does not smoke and never smoked (Go to PHL26)

PHL22. When did you quit smoking?
Record the period in complete years then go to PHL25

Time: _ _
Less than 1 year record 00
Don't know record 98

PHL23. For members who smoke cigarettes: How many cigarettes do you smoke daily?

[] 1 10 and less
[] 2 11-20
[] 3 21-40
[] 4 More than 40
[] 8 Don't know

PHL24. For members who smoke: for how long has (name) been smoking?
Record in complete years

Year: _ _
Less than 1 year record 00
Don't know record 98

PHL25. For members who are smoking and who smoked in the past:
How old was (name) when he/she started smoking?
Record the age in completed years

Age: _ _
Don't know record 98

For persons aged 12 years or over
[Note: PHL26 only]

PHL26. What is (name)'s current marital status?
Is he/she ?

[] 1 Single
[] 2 Engaged for the first time and not married yet
[] 3 Married
[] 4 Divorced
[] 5 Widow/widower
[] 6 Separated

PHL27. Interviewer: insert the line no of the eligible woman's husband from HL1
In case husband does not live in the household, record (00)

Number: _ _

PHL28. Interviewer: circle the line no of children 2-14 years eligible for interview for this age group

_ _ Circle the line no. [01-17]

PHL29. Interviewer: circle the line no of youth 15-29 years eligible for interview for this age group

_ _ Circle the line no. [01-17]

PHL30. Interviewer: circle the line no of elderly members 60 years and over eligible for interview for this age group

_ _ Circle the line no. [01-17]

Section 2: Chronic diseases: HL

PHL31. Does (name) have any disease according to a medical diagnosis and receives regular treatment?

[] 01 Hypertension
[] 02 Diabetes
[] 03 Peptic ulcer
[] 05 Cardiac disease
[] 06 Cancer
[] 07 Renal disease
[] 08 Hepatic disease
[] 09 Arthritis (rheumatism)
[] 10 Osteoporosis
[] 11 Thalassemia
[] 13 Epilepsy
[] 14 Asthma
[] 15 Back pain
[] 16 Gland diseases
[] 98 Don't know
[] 99 Healthy

Section 3: Education of household members: ED

For household members age 5 and above
[Note: ED3 to ED4A]

ED3. Is (name):

[] 0 Currently attending kindergarten
[] 1 Currently attending school
[] 2 Attended school and dropped out
[] 3 Attended school and graduated
[] 4 Never attended school (Go to ED4)
[] 8 Don't know
Grade: _ _
[] 98 DK
If less than 1 grade, enter 00.

ED4A. How many years of schooling did (name) successfully complete?

Year: _ _
[] 98 Don't know
Record (00) if schooling years are less than 1 year

ED4. What is (name)'s educational status?

[] 1 Illiterate
[] 02 Semi-literate
[] 03 Elementary
[] 04 Preparatory
[] 05 Secondary
[] 06 Associated diploma
[] 07 Bachelors degree
[] 08 Higher diploma
[] 09 Masters degree
[] 10 Ph D
[] 98 Don't know

For household members age 5-24 years
[Note: ED5 to ED8]

ED5. During the current school year, is (name) currently enrolled in school or kindergarten or university?

[] 1 Yes
[] 2 No (Go to ED7)

ED6. During the current school year at which educational level and which grade is (name) enrolled?

Level:

[] 0 Kindergarten
[] 1 Basic
[] 2 Secondary
[] 3 Higher
[] 8 DK

Grade: _ _
[] 98 DK
00 less than the first basic grade

ED7. During the past school year 2008-2009 was (name) enrolled in school or kindergarten or university in any time?

[] 1 Yes
[] 2 No (Go to next line)
[] 8 Don't know (Go to next line)

ED8. At which educational level and which grade was (name) enrolled in the past year?

Level:

[] 0 Kindergarten
[] 1 Basic
[] 2 Secondary
[] 3 Higher
[] 8 DK

Grade: _ _
[] 98 DK
00 less than the first basic grade

Water and sanitation module: WS

WS1. What is the main source of drinking water for members of your household?

[] 11 Public water network connected to the house
[] 21 Tubewell
[] 41 Protected spring
[] 51 Rain-fed cistern with internal pipes
[] 61 Tanker
[] 91 Bottled mineral water
[] 98 Purchased gallons
[] 96 Other (specify) ____

WS2. What is the main source of water used by your household for other purposes such as cooking and handwashing?

WS6. What do you usually do to the water to make it safer to drink?

[] 1 Yes
[] 2 No(Go to WS8)
[] 8 Don't know (Go to WS8)

WS7. How do you treat drinking water?

[] A Boil
[] B Chlorination
[] C Strain it through a cloth
[] D Filtering
[] F Let it stand and settle
[] X Other (specify) ____

WS8. What kind of toilet is used in this latrine?
One response only

[] 11Flush toilet connected to a sewage network
[] 12 Flush toilet connected to a septic tank
[] 13 Flush to pit
[] 14 Flush to unknown place
[] 95 No facility (Go to SI1)
[] 96 Other / specify _____

WS9. Does any other household share the use of this latrine with you?

[] 1 Yes, the latrine is shared
[] 2 No, the latrine is not shared

Section 6: Housing conditions: HC

PHC1. What kind of dwelling unit does the family live in?

[] 01 Villa
[] 02 House
[] 03 Apartment
[] 04 Separate room
[] 05 Tent
[] 06 Marginal
[] 96 Other / specify

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

No. of rooms: _ _

HC3. Main material of the dwelling floor:
Record observation.

[] 11 Earth floor
[] 21 Wood
[] 33 Ceramic tiles/marble
[] 34 Cement
[] 36 Bricks/stone
[] 96 Other (specify) ____

HC6. What type of fuel does your household mainly use for cooking?

[] 01 Electricity
[] 02 Gas
[] 05 Kerosene
[] 08 Firewood
[] 96 Other (specify) ____

HC8. Does your household have:

A. Electricity?

[] 1 Yes
[] 2 No

B. Radio/recorder

[] 1 Yes
[] 2 No

C. Television?

[] 1 Yes
[] 2 No

D. Telephone line

[] 1 Yes
[] 2 No

E. refrigerator?

[] 1 Yes
[] 2 No

F. Dishwasher

[] 1 Yes
[] 2 No

G. Central heating

[] 1 Yes
[] 2 No

H. Vacuum cleaner?

[] 1 Yes
[] 2 No

I. Home library?

[] 1 Yes
[] 2 No

J. Gas stove?

[] 1 Yes
[] 2 No

K. VCR/DVD?

[] 1 Yes
[] 2 No

L. Palestinian mobile?

[] 1 Yes
[] 2 No

M. Washing machine?

[] 1 Yes
[] 2 No

N. Cellular (Israeli)?

[] 1 Yes
[] 2 No

O. Computer?

[] 1 Yes
[] 2 No

P. Satellite dish?

[] 1 Yes
[] 2 No

Q. Internet services?

[] 1 Yes
[] 2 No

R. Solar heater?

[] 1 Yes
[] 2 No

S. Private car?

[] 1 Yes
[] 2 No

HC10. Is your dwelling?

[] 01 Owned
[] 02 Rented
[] 06 Not owned and not rented owned
[] 96 Other / specify: _____

Section 4: Child labor: CL

Now, I would like to ask about any type of work done by children in this household.

PCL1: Interviewer: Refer to question HL8:

[] 1 There are children 5-14 years old(Continue)
[] 2 No children in that age group (Go to PCD1(section 5))

CL1. Child's line number from HL1. _ _

PCL1. Mother's/ carer's line number from HL1. _ _

CL2. Names of children between 5-14 years: ____

CL3. During the past week did (name) any work for anybody from outside your household even if for one hour only?
(Interviewer: ask if the work was for pay or not)

[] 1 Yes, for pay (cash or in-kind)
[] 2 Yes, unpaid
[] 3 Didn't work (Go to CL7)

CL4. During the past week, how many hours did (name) spend in carrying out the work for the person from outside your household?

_ _ If there was more than one work, record the total number of hours.

CL7. During the past week, did (name) do any paid or unpaid work on a family farm or in a family business or selling goods in the street?
Include work for a business run by the child, alone or with one or more partners.

[] 1 Yes
[] 2 No (Go to CL9)

CL8. How many hours did he/she do this work for his/her family or himself/ herself during the past week? _ _

CL9. During the past week, did (name) help with household chores such as shopping, cleaning, washing clothes, cooking; or caring for children, old or sick people?

[] 1 Yes
[] 2 No (Go to next line)

CL10. How many hours did he/she spend doing these chores during the past week? _ _

Section 5: Child Discipline: CD

PCD1: Fill this section for one child aged between 2-14 years.
Refer to PHL28:

[] 1 If there is at least one child aged 2-14 year(Continue)
[] 2 If there are no children(Go to section 6 - Housing Characteristics)

List all children aged 2-14 years and use the attached table to select one child for the purpose of filling in this
section.

CD9.
Child's line no from HL1_ _
Child's name _____

PCD2. Child's age in full years from HL6_ _

PCD3. Line no of child's mother or carer from HL1_ _

CD10. Parents use certain methods to teach their children proper behaviour in their daily lives. I will read for you some of the methods used and would like to ask you to specify whether you or a member of your household have used these methods with (child's name) during the past month.

[] 1 Yes
[] 2 No

CD11. Withholding privileges, forbid something (name) liked or did not allow him/her to 1 2
leave house.

[] 1 Yes
[] 2 No

CD12. Explained why (name)'s behavior was wrong.

[] 1 Yes
[] 2 No

CD13. Shook him/her.

[] 1 Yes
[] 2 No

CD14. Shouted, yelled at or screamed at him/her.

[] 1 Yes
[] 2 No

CD15. Gave him/her something else to do.

[] 1 Yes
[] 2 No

CD16. Spanked, hit or slapped him/her on the bottom with bare hand.

[] 1 Yes
[] 2 No

CD17. Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.

[] 1 Yes
[] 2 No

CD18. Called him/her dumb, lazy, or another name like that.

[] 1 Yes
[] 2 No

CD19. Hit or slapped him/her on the face, head or ears.

[] 1 Yes
[] 2 No

CD20. Hit or slapped him/her on the hand, arm, or leg.

[] 1 Yes
[] 2 No

CD21. Hit him/her over and over as hard as possible.

[] 1 Yes
[] 2 No

CD22. Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished.

[] 1 Yes
[] 2 No
[] 8 Don't know/no opinion

Salt iodization module: SI

SI1. We want to test if there is iodine in the salt you use in your house.
Interviewer: take a sample of the salt and test it according to the training manual.
What is the test result?

[] 1 Not iodized (no color change) 0 PPM
[] 2 More than 0 PPM and less than 15 PPM (light color)
[] 3 15 PPM or more (dark color)
[] 6 No salt in home
[] 7 Salt not tested

PSI1. How do you save and store the salt in the house?

[] 1 Inside closed glass can
[] 2 Inside open glass can
[] 3 Inside plastic can
[] 4 In the same pocket
[] 6 Other/ determine

Palestinian Authority
Palestinian Central Bureau of Statistics
Palestinian Family Health Survey, 2010

Women (15- 54) Years Questionnaire: WM

All information in this questionnaire is for pure statistical purposes only. It is considered confidential in accordance with the Public Statistics Law of 2000.
This questionnaire is to be administered to all women age 15 - 54 regard less their marital status. Interviewer :
Now I will talk to you about your health and all women in the age (15-54) years health regard less their marital status, I will like to meet every one of them, who live in the same household.

WM1. Cluster number: _ _ _

WM2. Questionnaire's serial Num. in sample: _ _ _ _

PWM1. Governorate: _ _

PWM2. Locality: _ _ _ _ _ _

PWM3. Household number: _ _

PWM4. Building's address: _____

PWM5. Name of head of household: _____

Interviewer record:
WM6. Visits' schedule

[] 1st visit: Day_ _ Month _ _Starting time _____ Ending time _____
[] 2nd visit: Day_ _ Month _ _Starting time _____ Ending time _____
[] 3rd visit: Day_ _ Month _ _Starting time _____ Ending time _____

Interviewer record:
PWM6. Total No of visits: _

Interviewer record:
WM7. Result of woman's interview

[] 01 Completed
[] 02 Not at home/ Unable to interview the woman
[] 03 Refused
[] 04 Partially completed
[] 05 No eligible woman
[] 07 Information Not available
[] 96 Other/specify ______

Interviewer record:
PWM7. Total No of eligible women: _ _

Interviewer record:
PWM8. Total No of eligible women interviewed: _ _

Interviewer record:
WM8. Interviewer name and number:

Name: _____
Number: _ _ _ _ _

Interviewer record:
WM9. Supervisor name and number:

Name: _____
Number: _ _ _ _ _

Interviewer record:
WM10. Field edited by name and number:

Name: _____
Number: _ _ _ _ _

Interviewer record:
WM11. Data entry clerk name and number: _ _

Name: _____
Number: _ _ _ _ _

PHH12. Date of entrying: _ _/_ _/2010

Section 7: Women's Health: WH

Interviewer: ask the following questions to all women aged 15-54 years regardless of their marital status.

PWH1. Name of eligible woman (15-54 years) from HL2:

[] A. First woman: _____
[] B. Second woman: ______
[] C. Third woman: _____

PWH2. Woman's line No. from HL1:

A. First woman: _ _
B. Second woman: _ _
C. Third woman: _ _

PWH3. How do you evaluate your health?

[] 1. Excellent
[] 2. Good
[] 3. Moderate
[] 4. Acceptable
[] 5. Bad
[] 6. Very bad

PWH4. Compared to the past year, do you consider that your health has improved, stayed the same or worsened?

[] 1. Improved
[] 2. The same
[] 3. Worsened
[] 96. Other(specify): _____

PWH5. Do you think that your weight:

[] 1. Matches with your height
[] 2. Less than it should be compared to your height
[] 3. Much less than it should be, compared to your height
[] 4. More than it should be compared to your height
[] 5. Much more than it should be

PWH6. Do you practice physical exercises:

[] 1. More than 3 times a week
[] 2. 3 times a week or less
[] 3. Sometimes
[] 4. More than it should be compared to your height
[] 5. Do not practice at all

PWH7. Did you have a health problem during the past two weeks?

[] 1. Yes
[] 2. No (Go to PWH11)

PWH7A. Did you see anyone about this health problem?

[] 1. Yes
[] 2. No (Go to PWH10)

PWH9. When you had this problem, did you seek consultation at the following?
Interviewer : after answer the question, skip to PWH11

[] A. Doctor's clinic
[] B. Hospital
[] C. Health center
[] D. Pharmacy
[] E. Traditional healer
[] F. Self treatment

PWH10. For women who did not see anybody for their illness, why did not you see anybody?

Condition did not require

[] 1. Yes
[] 2. No

B. Financial reasons

[] 1. Yes
[] 2. No

C. Difficult to access the provided services

[] 1. Yes
[] 2. No

D. Social reasons hindering access

[] 1. Yes
[] 2. No

E. Busy/No time

[] 1. Yes
[] 2. No

PWH11. Do you suffer from anemia?

[] 1. Yes
[] 2. No (Go to PWH14)
[] 3. Don't know(Go to PWH14)

PWH12. For women suffering from anemia, how did you know that you suffer from anemia?

[] 1. Diagnosed by a doctor / clinic / hospital
[] 2. Through symptoms
[] 3. Other / specify_____

PWH13. What did you do when you knew that you have anemia?

[] 1. Saw a doctor who prescribed treatment for me
[] 2. Bought medicine from the pharmacy
[] 3. Improved nutrition
[] 4. Nothing
[] 3. Other / specify_____

PWH14. In general where do you go when you feel ill?

[] 1. Governmental clinic/center
[] 2. UNRWA clinic/center
[] 3. NGO clinic/center
[] 4. Private clinic
[] 5. Hospital
[] 6. Seek care from traditional healers
[] 7. Other / specify_____
[] 8. Nowhere

PWH15. Interviewer: refer to HL6:

[] 1. the interviewee's age is 30-54 years, proceed with the questions 2
[] 2. No (Go to section eight on Aids)

PWH16. Have you carried out a pap smear test at least once every 3 years?

[] 1. Yes
[] 2. No

PWH17. Do you perform manual breast self-examination?

[] 1. Once per month
[] 2. Once every few months
[] 3. Other
[] 3. No (Go to PWH20)

PWH18. Did you receive any instructions from anyone about manual breast self-examination?

[] 1. Yes
[] 2. No (Go to PWH20)

PWH19. From where did you receive the instructions about manual breast self-examination?

[] 1. Private doctor
[] 2. Hospital/governmental health center
[] 3. Hospital /NGO health center
[] 4. Hospital/ UNRWA health center
[] 5. Private hospital/ health center
[] 6. Mass media
[] 8. Other / specify ____

PWH20. Interviewer: women's age

[] 1. Less than 35 years (Go to section eight: Aids disease )
[] 2. 35 year and more (Continue 2)

PWH21. Do you perform breast mammogram?

[] 1. Once every year
[] 2. Once every two years
[] 3. Not at all

Section 8: HIV/AIDS: HA

HA1. Now I would like to talk with you about something else.
Have you ever heard of an illness called AIDS?

[] 1. Yes
[] 2. No (Go to the next woman if present, or to questionnaire of evermarried women)

HA2. In your opinion, can people reduce their chance of getting the AIDS virus by having just one uninfected sex partner who has no other sex partners?