MICS Household Questionnaire
Household Information Panel: HH
HH1. Cluster number: _ _ _
HH2. Household number: _ _
HH3. Interviewer name and ID code
Name ____
ID code _ _
ID code _ _
HH4. Supervisor name and ID code:
Name ____
ID code _ _
ID code _ _
HH5. Day/month/year of interview
_ _ / _ _ /2014
HH6. Area
[] 1 Urban
[] 2 Other
[] 2 Other
HH7. Region
[] 1 Belgrade
[] 2 Vojvodina
[] 3 Sumadija and West Serbia
[] 4 South and East Serbia
[] 2 Vojvodina
[] 3 Sumadija and West Serbia
[] 4 South and East Serbia
We are from Statistical Office of The Republic Of Serbia. We are conducting a survey about the situation of children, families and households. I would like to talk to you about these subjects. The interview will take about 30 minutes. All the information we obtain will remain strictly confidential and anonymous. May I start now?
[] Yes, permission is given (Go to HH18 to record the time and then begin the interview.)
[] No, permission is not given ( Circle ?04? HH9. Discuss this result with your supervisor.)
[] No, permission is not given ( Circle ?04? HH9. Discuss this result with your supervisor.)
HH9. Result of household interview:
[] 01 Completed
[] 02 No household member or no competent respondent at home at time of visit
[] 03 Entire household absent for extended period of time
[] 04 Refused
[] 05 Dwelling vacant/address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
[] 02 No household member or no competent respondent at home at time of visit
[] 03 Entire household absent for extended period of time
[] 04 Refused
[] 05 Dwelling vacant/address not a dwelling
[] 06 Dwelling destroyed
[] 07 Dwelling not found
[] 96 Other (specify) ____
After the household questionnaire has been completed, fill in the following information:
HH10. Respondent to household questionnaire:
Name: ____ _ _
Respondent?s line number in Module HL:___
Respondent?s line number in Module HL:___
After the household questionnaire has been completed, fill in the following information:
HH11. Total number of household members: _ _
After the household questionnaire has been completed, fill in the following information:
HH12. Number of women age 15-49 years: _ _
After all questionnaires for the household have been completed, fill in the following information:
HH13. Number of women's questionnaires completed: _ _
After the household questionnaire has been completed, fill in the following information:
If the household is selected for Questionnaire for Men
After the household questionnaire has been completed, fill in the following information:
HH14. Number of children under age 5: _ _
After all questionnaires for the household have been completed, fill in the following information:
HH15. Number of under-5 questionnaires completed: _ _
HH16. Field editor's name and ID code:
____ Name
_ _ ID code
_ _ ID code
HH17. Main data entry clerk's name and ID code:
____ Name
_ _ ID code
_ _ ID code
HH18 Record the time
_ _ Hour
_ _ Minuets
_ _ Minuets
List of Household Members: 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?
If yes, complete listing for questions HL2-HL4. Then, ask questions starting with HL5 for each person at a time. Use an additional questionnaire if all rows in the household listing form have been used.
HL1. Line number: _ _
HL2. Name: ____
HL3. What is the relation-ship of (name) to the head of household?
Relation: _ _
HL4. Is the (name) Male or Female?
[] 1 Male
[] 2 Female
[] 2 Female
HL5. What is (name's) date of birth?
Month (98 DK): _ _
Year (9998 DK): _ _ _ _
Year (9998 DK): _ _ _ _
HL6. How old is (name)?
Record in completed years. If age is 95 or above '95':
Age: _ _
For women age 15-49
HL7. Circle line no. If women age 15-49.
HL7B. Circle line no. If children age 0-4.
HL11. Is (name)'s natural mother alive
[] 1 Yes
[] 2 No (Go to HL13)
[] 8 DK (Go to HL13)
[] 2 No (Go to HL13)
[] 8 DK (Go to HL13)
HL12. Does (name)'s natural mother live in this household? _ _
If "Yes", record line no. of mother and go to HL13. If "No", record 00.
HL12A. Where does (name)'s natural mother live?
[] 1 In another household in this country
[] 2 Institution in this country
[] 3 Abroad
[] 8 DK
[] 2 Institution in this country
[] 3 Abroad
[] 8 DK
HL13. Is (name)'s natural father alive
[] 1 Yes
[] 2 No (Go to HL15)
[] 8 DK (Go to HL15)
[] 2 No (Go to HL15)
[] 8 DK (Go to HL15)
HL14. Does (name)'s natural father live in this household? _ _
If "Yes", record line no. of father and go to HL15. If "No", record 00.
HL14A. Where does (name)'s natural father live?
[] 1 In another household in this country
[] 2 Institution in this country
[] 3 Abroad
[] 4 DK
[] 2 Institution in this country
[] 3 Abroad
[] 4 DK
HL15. Record line no. of mother from HL12 if indicated.
If HL12 is blank or '00' ask: who is the primary caretaker of (name)?
For children age 0-14
Number: _ _
[] Enter X here if additional questionnaire is used
Probe for additional household members. Probe especially for any infants or small children not listed, and others who may not be members of the family (such as servants, friends) but who usually live in the household. Insert names of additional members in the household list and complete form accordingly.
Now for each woman age 15-49 years, write her name and line number and other identifying information in the information panel of a separate individual women's questionnaire.
For each man age 15-49 years, write his name and line number and other identifying information in the information panel of a separate individual man'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 a separate under-5 questionnaire.
You should now have a separate questionnaire for each eligible woman, each eligible man, and each child under five in the household.
Code for HL3 Relationship to head of household
[] 01 Head
[] 02 Wife/husband
[] 03 Son/daughter
[] 04 Son-in-law/daughter-in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother/sister
[] 09 Brother-in-law/sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew
[] 12 Other relative
[] 13 Adopted/foster/stepchild
[] 14 Servant (live-in)
[] 96 Other (not related)
[] 98 DK
[] 02 Wife/husband
[] 03 Son/daughter
[] 04 Son-in-law/daughter-in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother/sister
[] 09 Brother-in-law/sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew
[] 12 Other relative
[] 13 Adopted/foster/stepchild
[] 14 Servant (live-in)
[] 96 Other (not related)
[] 98 DK
Education: ED
ED1. Line number: _ _
ED2. Name and age
Copy from HL2 and HL6.
Name: ____
Age: _ _
Age: _ _
ED3. Has (name) ever attended school or pre-school?
For household members age 5 and above
[] 1. Yes
[] 2. No (Go to next line)
[] 2. No (Go to next line)
ED4A. What is the highest level school (name) has ever attended?
For household members age 5 and above. If level=0, skip to ED5
[] 0 Kindergarten
[] 1 Preparatory preschool program (PPP)
[] 2 Primary school
[] 3 Secondary
[] 4 Higher
[] 8 DK
[] 1 Preparatory preschool program (PPP)
[] 2 Primary school
[] 3 Secondary
[] 4 Higher
[] 8 DK
ED4B. What is the highest grade (name) completed at this level?
For household members age 5 and above. If the first grade at this level is not completed, enter "00".
Grade: _ _
[]98. DK
[]98. DK
ED5. During the current school year, that is 2013-2014, did (name) attend school or preschool at any time?
For household members age 5-24 years
[] 1. Yes
[] 2. No (Go to ED7)
[] 2. No (Go to ED7)
ED6. During this/that school year, which level and grade is/was (name) attending?
For household members age 5-24 years. If level=0 skip to ED7
Level:
[] 0 Kindergarten
[] 1 Preparatory preschool program (PPP)
[] 2 Primary school
[] 3 Secondary
[] 4 Higher
[] 8 DK
[] 1 Preparatory preschool program (PPP)
[] 2 Primary school
[] 3 Secondary
[] 4 Higher
[] 8 DK
Grade:
_ _
[] 98 DK
[] 98 DK
ED7. During the previous school year, that is 2012-2013, did (name) attend school or preschool at any time?
For household members age 5-24 years
[] 1 Yes
[] 2 No (Go to ED8C)
[] 8 DK (Go to ED8C)
[] 2 No (Go to ED8C)
[] 8 DK (Go to ED8C)
ED8. During that previous school year, which level and grade did (name) attend?
For household members age 5-24 years
If level=0 skip to ED7
Level:
[] 0 Kindergarten
[] 1 Preparatory preschool program (PPP)
[] 2 Primary school
[] 3 Secondary
[] 4 Higher
[] 8 DK
[] 1 Preparatory preschool program (PPP)
[] 2 Primary school
[] 3 Secondary
[] 4 Higher
[] 8 DK
Grade:
_ _
[] 98. DK
[] 98. DK
ED8C. Check ED6. If level=0 or 1 go to next line. For all other levels ask:
At what age did (name) start the first grade of primary school?
Record in completed years
[]98. DK
Education (Attendance to Compulsory Preparatory Preschool Program - PPP)
ED8D. Check ED2, are there children aged 5-7 years living in the household?
[] Yes (Continue with ED9 and copy the line number from ED1 and name and age from ED2 for all children aged 5-7 years.)
[] No (go to next module)
ED9. Line number: _ _
Copy from ED1
ED10. Name and age
Copy names and age from ED2.
Name: ____
Age: _ _
Age: _ _
ED11. Does (name) attend/attended a PPP?
[] 1. Yes
[] 2. No if child is 6 or 7 years (Go to ED15)
if child is 5 years (Go to next line)
[] 2. No if child is 6 or 7 years (Go to ED15)
if child is 5 years (Go to next line)
ED12. In what type of facility does (name) attend the PPP, or did attend the PPP during the previous school year?
[] 1. Public kindergarten
[] 2. Private kindergarten
[] 3. School
[] 4. Facility sponsored by Roma NGO
[] 5. Facility sponsored by other NGO
[] 6. Denominational facility
[] 96. Other
[] 2. Private kindergarten
[] 3. School
[] 4. Facility sponsored by Roma NGO
[] 5. Facility sponsored by other NGO
[] 6. Denominational facility
[] 96. Other
ED13. How does/did (name) usually goes/went to PPP?
[] 1. Walks
[] 2. Bicycle
[] 3. Public transportation
[] 4. Private car or motorcycle
[] 5. Organized transportation to the facility
[] 6. Other
[] 2. Bicycle
[] 3. Public transportation
[] 4. Private car or motorcycle
[] 5. Organized transportation to the facility
[] 6. Other
ED14. What is the distance in km from your home to the PPP facility, when using the usual way/mean of transportation to get there?
[] 98 DK
[] __Km ___Minutes(Go to next line)
[] __Km ___Minutes(Go to next line)
ED15. What are the main reasons of nonattendance of preparatory preschool program?
[] A. The child will not learn anything important in PPP
[] B. Disabled
[] C. Groups overcrowded, lack of attention
[] D. Inadequate treatment
[] E. Didn?t know it is compulsory
[] F. Overcrowded facility
[] G. Too far
[] H. The child does not have necessary documents
[] I. No one can take child to PPP
[] J. Cost of transportation
[] K. Textbooks/school supplies/pens
[] L. Clothes
[] M. Food
[] N. Hygiene expenses
[] X. Other
[] B. Disabled
[] C. Groups overcrowded, lack of attention
[] D. Inadequate treatment
[] E. Didn?t know it is compulsory
[] F. Overcrowded facility
[] G. Too far
[] H. The child does not have necessary documents
[] I. No one can take child to PPP
[] J. Cost of transportation
[] K. Textbooks/school supplies/pens
[] L. Clothes
[] M. Food
[] N. Hygiene expenses
[] X. Other
Selection of One Child For Child Labour/Child Discipline: SL
SL1. Check HL6 in the list of household members and write the total number of children age 1-17 years.
Total number: _
SL2. Check the number of children age 1-17 years in SL1:
[] Zero (Go to Module AC-Attitudes toward Children with disabilities.)
[] One (Go to SL9 and record the rank number as "1", enter the line number, child's name and age.)
[] Two or more (Continue with SL2A.)
[] One (Go to SL9 and record the rank number as "1", enter the line number, child's name and age.)
[] Two or more (Continue with SL2A.)
SL2A. List each of the children age 1-17 years below in the order they appear in the List of household members. Do not include other household members outside of the age range 1-17 years. Record the line number, name, sex, and age for each child.
SL3. Rank number: _
SL4. Line number from HL1: _ _
SL5. Name from HL2: ____
SL6. Sex from HL4
[] 1 Male
[] 2 Female
[] 2 Female
SL7. Age from HL6: _ _
SL8. Check the last digit of the household number (HH2) from the cover page. This is the number of the row you should go to in the table below.
Check the total number of children age 1-17 years in SL1 above. This is the number of the column you should go to in the table below.
Find the box where the row and the column meet and circle the number that appears in the box. This is the rank number (SL3) of the selected child from the table question SL2A, and for this child you need to write date in SL9
Last Digit of Household Number (from HH2): _
Total Number of Eligible Children in the Household (from SL1): [2 to 8+] _
Total Number of Eligible Children in the Household (from SL1): [2 to 8+] _
SL9. Record the rank number (SL3), line number (SL4), name (SL5) and age (SL7) of the selected child.
Rank number: _
Line number: _ _
Name: ____
Age: _ _
Line number: _ _
Name: ____
Age: _ _
Child Labor: CL
CL1. Check selected child's age from SL9:
[] 1-4 years (Go to next module)
[] 5-17 years (Continue with CL2)
[] 5-17 years (Continue with CL2)
CL2. Now I would like to ask about any work children in this household may do.
Since last (day of the week), did (name) do any of the following activities, even for only one hour?
A. Did (name) do any work or help on his/her own or the household's plot/farm/food garden or looked after animals? For example, growing farm produce, harvesting, or feeding, grazing, milking animals?
[] 1 Yes
[] 2 No
[] 2 No
B. Did (name) help in family business or relative's business with or without pay, or run his/her own business?
[] 1 Yes
[] 2 No
[] 2 No
C. Did (name) produce or sell articles, handicrafts, clothes, food or agricultural products?
[] 1 Yes
[] 2 No
[] 2 No
D. Since last (day of the week), did (name) engage in any other activity in return for income in cash or in kind, even for only one hour?
If "No", Probe: Please include any activity (name) performed as a regular or casual employee, self-employed or employer; or as an unpaid family worker helping out in household business or farm.
[] 1 Yes
[] 2 No
[] 2 No
CL3. Check CL2, A to D
[] There is at least one "yes" (Continue with CL4)
[] All answers are "No" (Go to CL8)
[] All answers are "No" (Go to CL8)
CL4. Since last (day of the week) about how many hours did (name) engage in this activity/these activities, in total?
If less than one hour, record "00"
Number of hours: _ _
CL5. Does the activity/do these activities require carrying heavy loads?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
CL6. Does the activity/do these activities require working with dangerous tools (knives etc.) or operating heavy machinery?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
CL7. How would you describe the work environment of (name)?
[A] Is (name) exposed to dust, fumes or gas?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[B] Is (name) exposed to extreme cold, heat or humidity?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[C] Is (name) exposed to loud noise or vibration?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[D] Is (name) required to work at heights?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[E] Is (name) required to work with chemicals (pesticides, glues, etc.) or explosives?
[] 1 Yes (Go to CL8)
[] 2 No
[] 2 No
[F] Is (name) exposed to other things, processes or conditions bad for (name)'s health or safety?
[] 1 Yes
[] 2 No
[] 2 No
CL8. Since last (day of the week), did (name) fetch water or collect firewood for household use?
[] 1 Yes
[] 2 No (Go to CL10)
[] 2 No (Go to CL10)
CL9. In total, how many hours did (name) spend on fetching water or collecting firewood for household use, since last (day of the week)?
If less than one hour, record "00"
Number of hours: _ _
CL10. Since last (day of the week), did (name) do any of the following for this household?
[A] Shopping for household?
[] 1 Yes
[] 2 No
[] 2 No
[B] Repair any household equipment?
[] 1 Yes
[] 2 No
[] 2 No
[C] Cooking or cleaning utensils or the house?
[] 1 Yes
[] 2 No
[] 2 No
[D] Washing clothes?
[] 1 Yes
[] 2 No
[] 2 No
[E] Caring for children?
[] 1 Yes
[] 2 No
[] 2 No
[F] Caring for the old or sick?
[] 1 Yes
[] 2 No
[] 2 No
[G] Other household tasks?
[] 1 Yes
[] 2 No
[] 2 No
CL11 Check CL10, A to G
[] There is at least one "yes" (Continue with CL12)
[] All answers are "no" (Go to next module)
[] All answers are "no" (Go to next module)
CL12. Since last (day of the week), about how many hours did (name) engage in this activity/these activities, in total?
If less than one hour, record "00"
Number of hours: _ _
Child Discipline: CD
CD1. Check selected child's age from SL9
[] 1-14 years (Continue with CD2)
[] 15-17 years (Go to next module)
[] 15-17 years (Go to next module)
CD2. Write the line number and name of the child from SL9.
Line number: _ _
Name: ____
Name: ____
CD3. Adults use certain ways to teach children the right behaviour or to address a behaviour problem. I will read various methods that are used. Please tell me if you or anyone else in your household has used this method with (name) in the past month.
[A] Took away privileges, forbade something (name) liked or did not allow him/her to leave the house.
[] 1 Yes
[] 2 No
[] 2 No
[B] Explained why (name)'s behaviour was wrong.
[] 1 Yes
[] 2 No
[] 2 No
[C] Shook him/her.
[] 1 Yes
[] 2 No
[] 2 No
[D] Shouted, yelled at or screamed at him/her.
[] 1 Yes
[] 2 No
[] 2 No
[E] Gave him/her something else to do.
[] 1. Yes
[] 2. No
[] 2. No
[F] Spanked, hit or slapped him/her on the bottom with bare hand.
[] 1 Yes
[] 2 No
[] 2 No
[G] 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
[] 2 No
[H] Called him/her dumb, lazy, or another name like that.
[] 1 Yes
[] 2 No
[] 2 No
[I] Hit or slapped him/her on the face, head or ears.
[] 1 Yes
[] 2 No
[] 2 No
[J] Hit or slapped him/her on the hand, arm, or leg.
[] 1 Yes
[] 2 No
[] 2 No
[K] Beat him/her up, that is hit him/her over and over as hard as one could.
[] 1 Yes
[] 2 No
[] 2 No
CD4. 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 DK/no opinion
[] 2 No
[] 8 DK/no opinion
Attitudes Toward Children With Disabilities: AC
AC1. Now, I will read a few statements related to children disabilities:
If necessary, explain to the respondent that the persons with disabilities include those who long-term physical, mental, intellectual or sensory impairments which in interaction with various barriers may hinder their full and effective participation in society on equal basis with others.
The following statements refer only to children with physical and sensory disabilities.
After I read each statement, please answer to what extend you agree with the statement. There are five possible answers: strongly disagree, disagree, neither agree nor disagree, agree, strongly agree. Now I will read statements.
A. For these children it is better to live in the family than in a specialised child care institution.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
B. These children negatively impact the everyday lives of other children in the family.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
C. For these children it is better to attend a mainstream school than a special school.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
D. These children negatively impact the work of other students in mainstream schools
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
E. These children can achieve a lot in life if they are adequately supported.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
AC2. The following statements refer only to children with intellectual disabilities
A. For these children it is better to live in the family than in specialized child care institutions.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
B. These children negatively impact the everyday lives of other children in the family.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
C. For these children it is better to attend mainstream schools than special schools.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
D. These children negatively impact the work of other students in mainstream schools
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
E. These children can achieve a lot in life if they are adequately supported.
[] 1. Strongly disagree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
[] 2. Mostly disagree
[] 3. Neither agree or disagree
[] 4. Mostly agree
[] 5. Strongly agree
Household Characteristics: HC
HC1A. What is the religion of the head of this household?
[] 1 Orthodox
[] 2 Catholic
[] 3 Islamic
[] 4 Does not want to declare
[] 6 Other religion (specify) ____
[] 7 No religion
[] 2 Catholic
[] 3 Islamic
[] 4 Does not want to declare
[] 6 Other religion (specify) ____
[] 7 No religion
HC1C. To what ethnic group does the head of this household belong?
[] 1 Serbian
[] 2 Hungaran
[] 3 Bosnian
[] 4 Roma
[] 6 Other language (specify) ____
[] 8 Does not want to declare
[] 2 Hungaran
[] 3 Bosnian
[] 4 Roma
[] 6 Other language (specify) ____
[] 8 Does not want to declare
HC2. How many rooms in this household are used for sleeping?
Number of rooms: _ _
HC3. Main material of the dwelling floor.
Record observation.
Natural floor
[] 11 Earth
Rudimentary floor
[] 21 Wood planks
Finished floor
[] 31 Parquet or polished wood
[] 32 Vinyl or asphalt strips
[] 33 Ceramic tiles
[] 34 Cement
[] 35 Carpet
[] 36 Laminate
[] 32 Vinyl or asphalt strips
[] 33 Ceramic tiles
[] 34 Cement
[] 35 Carpet
[] 36 Laminate
[] 96. Other (specify) ____
HC4. Main material of the roof.
Record observation.
Natural roofing
[] 11 No roof
[] 12 Thatch
[] 12 Thatch
Rudimentary roofing
[] 22 Cane
[] 23 Wood planks
[] 24 Cardboard
[] 23 Wood planks
[] 24 Cardboard
Finished roofing
[] 31 Metal/Tin
[] 32 Wood
[] 33 Calamine/cement fibre
[] 34 Ceramic tiles
[] 35 Cement
[] 36 Roofing shingles
[] 96 Other (specify) ____
[] 32 Wood
[] 33 Calamine/cement fibre
[] 34 Ceramic tiles
[] 35 Cement
[] 36 Roofing shingles
[] 96 Other (specify) ____
HC5. Main material of the exterior walls.
Record observation
Natural walls
[] 11 No walls
[] 12 Cane/palm/trunks
[] 13 Mud
[] 12 Cane/palm/trunks
[] 13 Mud
Rudimentary walls
[] 21 Cane, straw and mud
[] 22 Stone with mud
[] 23 Uncovered adobe
[] 24 Plywood
[] 25 Cardboard
[] 26 Reused wood
[] 22 Stone with mud
[] 23 Uncovered adobe
[] 24 Plywood
[] 25 Cardboard
[] 26 Reused wood
Finished Walls
[] 31 Cement
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement bricks
[] 35 Covered adobe
[] 36 Wood planks/shingles
[] 37 Plaster Walls
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement bricks
[] 35 Covered adobe
[] 36 Wood planks/shingles
[] 37 Plaster Walls
[] 96 Other (specify) ____
HC6. What type of fuel does your household mainly use for cooking?
[] 01 Electricity (Go to HC8)
[] 02 Liquefied petroleum gas (LPG) (Go to HC8)
[] 03 Natural gas (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene (Go to HC8)
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 11 Agricultural crop residue
[] 95 No food cooked in household (Go to HC8)
[] 96 Other (specify) ____
[] 02 Liquefied petroleum gas (LPG) (Go to HC8)
[] 03 Natural gas (Go to HC8)
[] 04 Biogas (Go to HC8)
[] 05 Kerosene (Go to HC8)
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 11 Agricultural crop residue
[] 95 No food cooked in household (Go to HC8)
[] 96 Other (specify) ____
HC7. Is the cooking usually done in the house, in a separate building, or outdoors?
If 'In the house', probe: is it done in a separate room used as a kitchen?
In the house
[] 1 In a separate room used as a kitchen
[] 2 Elsewhere in the house
[] 2 Elsewhere in the house
[] 3 In a separate building
[] 4 Outdoors
[] 6 Other (specify) ____
[] 4 Outdoors
[] 6 Other (specify) ____
HC8. Does your household have:
[A] Electricity?
[] 1 Yes
[] 2 No
[] 2 No
[B] A radio?
[] 1 Yes
[] 2 No
[] 2 No
[C] A television?
[] 1 Yes
[] 2 No
[] 2 No
[D] A non-mobile telephone?
[] 1 Yes
[] 2 No
[] 2 No
[E] A refrigerator?
[] 1 Yes
[] 2 No
[] 2 No
[F] A wardobe
[] 1 Yes
[] 2 No
[] 2 No
[G] A table with chairs
[] 1 Yes
[] 2 No
[] 2 No
[H] A bed
[] 1 Yes
[] 2 No
[] 2 No
I. An iron?
[] 1. Yes
[] 2. No
[] 2. No
J. A hair dryer?
[] 1. Yes
[] 2. No
[] 2. No
K. A water heater?
[] 1. Yes
[] 2. No
[] 2. No
L. A vacuum cleaner?
[] 1. Yes
[] 2. No
[] 2. No
M. A freezer?
[] 1. Yes
[] 2. No
[] 2. No
N. An electrical stove?
[] 1. Yes
[] 2. No
[] 2. No
O. A washing machine?
[] 1. Yes
[] 2. No
[] 2. No
P. A drying machine?
[] 1. Yes
[] 2. No
[] 2. No
Q. A dishwasher?
[] 1. Yes
[] 2. No
[] 2. No
R. A microwave?
[] 1. Yes
[] 2. No
[] 2. No
S. A cable TV/Total TV?
[] 1. Yes
[] 2. No
[] 2. No
T. A PC/ laptop?
[] 1. Yes
[] 2. No
[] 2. No
U. An internet
[] 1. Yes
[] 2. No
[] 2. No
V. An Air conditioner?
[] 1. Yes
[] 2. No
[] 2. No
HC9. Does any member of your household own:
[A] A wrist watch?
[] 1 Yes
[] 2 No
[] 2 No
[B] A mobile telephone?
[] 1 Yes
[] 2 No
[] 2 No
[C] A bicycle?
[] 1 Yes
[] 2 No
[] 2 No
[D] A motorcycle or scooter?
[] 1 Yes
[] 2 No
[] 2 No
[E] An animal-drawn cart?
[] 1 Yes
[] 2 No
[] 2 No
[I] A car?
[] 1 Yes
[] 2 No
[] 2 No
[J] A truck?
[] 1 Yes
[] 2 No
[] 2 No
[K] A tractor?
[] 1 Yes
[] 2 No
[] 2 No
HC10. Do you or someone living in this household own this dwelling?
If "No", then ask: Do you rent this dwelling from someone not living in this household?
If "Rented from someone else", circle "2". For other responses, circle "6".
[] 1 Own
[] 2 Rent
[] 6 Other (specify) ____
[] 2 Rent
[] 6 Other (specify) ____
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 less than one, record "00". If 95 or more, record '95'. If unknown, record '98'.
Hectares: _ _
HC13. Does this household own any livestock, herds, other farm animals, or poultry?
[] 1 Yes
[] 2 No (Go to HC15)
[] 2 No (Go to HC15)
HC14. How many of the following animals does this household have?
If none, record '00'. If 95 or more, record '95'. If unknown, record '98'.
[A] Cattle, milk cows, or bulls?
Numbers: _ _
[B] Horses, donkeys, or mules?
Numbers: _ _
[C] Goats?
Numbers: _ _
[D] Sheep?
Numbers: _ _
[E] Chickens?
Numbers: _ _
[F] Pigs?
Numbers: _ _
[G] Other poultry
Numbers: _ _
[H] Beehives
Numbers: _ _
HC15. Does any member of this household have a bank account?
[] 1. Yes
[] 2. No
[] 2. No
Cash Benefit: CB
CB1. I would like to ask you about cash benefit programs:
Did you know that there are various cash benefit programs provided by government/city/municipal institutions?
[A] Financial social assistance-FSA?
[] 1 Yes
[] 2 No
[] 2 No
[B] Child allowance?
[] 1 Yes
[] 2 No
[] 2 No
[C] One-off social assistance?
[] 1 Yes
[] 2 No
[] 2 No
[D] Disability allowance?
[] 1 Yes
[] 2 No
[] 2 No
CB2. Have you applied or renewed application for the financial social assistance during the past 12 months?
[] 1 Yes
[] 2 No(Go to CB5)
[] 2 No(Go to CB5)
CB3. Were you approved the financial social assistance based on this request?
[] 1 Yes
[] 2 No(Go to CB6)
[] 3 Don?t know / waiting for answer
[] 2 No(Go to CB6)
[] 3 Don?t know / waiting for answer
CB4. Whether and for how long have you been receiving this allowance even if there were break periods?
[] 1. Less than 12 months (Go to CB6)
[] 2. 1-3 years (Go to CB6)
[] 3. 4-5 years (Go to CB6)
[] 4. More than 5 years (Go to CB6)
[] 5. He/ She never received allowance (Go to CB6)
[] 2. 1-3 years (Go to CB6)
[] 3. 4-5 years (Go to CB6)
[] 4. More than 5 years (Go to CB6)
[] 5. He/ She never received allowance (Go to CB6)
CB5. What?s the main reason you did not apply for the financial social assistance?
[] 1. Did not need any
[] 2. Unaware of the program
[] 3. Did not know how to apply
[] 4. Complicated administrative procedure
[] 5. Expensive administrative procedure
[] 6. I know I do not meet conditions
[] 7. I was told I do not meet conditions
[] 96. Other(specify)____
[] 2. Unaware of the program
[] 3. Did not know how to apply
[] 4. Complicated administrative procedure
[] 5. Expensive administrative procedure
[] 6. I know I do not meet conditions
[] 7. I was told I do not meet conditions
[] 96. Other(specify)____
CB6 . Check if there are children ages 0-18 years in the household
[] Yes (Continue with CB7)
[] No (go to next module)
CB7. Line number: _ _
Copy from HL1
CB8. Name and age
Copy names and age from HL2 and HL6.
Name: ____
Age: _ _
Age: _ _
CB9. Have you applied or renewed application for child allowance in the past 12 months for (name)?
[] 1. Yes
[] 2. No (Go to CB12)
[] 2. No (Go to CB12)
CB10. Were you approved the child allowance for (name) based on this request?
[] 1. Yes
[] 2. Don?t know / Waiting for answer
[] 3. No (Go to next line)
[] 2. Don?t know / Waiting for answer
[] 3. No (Go to next line)
CB11. Whether and for how long have you been receiving this allowance for (name)?
[] 1. Less than 12 months
[] 2. 1-3 years
[] 3. 4-5 years
[] 4. More than 5 years
[] 5. He/ She never received allowance
[] 2. 1-3 years
[] 3. 4-5 years
[] 4. More than 5 years
[] 5. He/ She never received allowance
CB12. Please tell me what is the main reason you did not apply for child benefit for (name)?
[] 1. Did not need any
[] 2. Unaware of the program
[] 3. Did not know how to apply
[] 4. Complicated administrative procedure
[] 5. Expensive administrative procedure
[] 6. I know I do not meet conditions
[] 7. I was told I do not meet conditions
[] 96. Other (specify)____
[] 2. Unaware of the program
[] 3. Did not know how to apply
[] 4. Complicated administrative procedure
[] 5. Expensive administrative procedure
[] 6. I know I do not meet conditions
[] 7. I was told I do not meet conditions
[] 96. Other (specify)____
Water and Sanitation: WS
WS1. What is the main source of drinking water used by members of your household?
Piped water
[] 11 Piped into dwelling (Go to WS6)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped into neighbour (Go to WS6)
[] 14 Public tap/standpipe (Go to WS3)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped into neighbour (Go to WS6)
[] 14 Public tap/standpipe (Go to WS3)
[] 21. Tube well, borehole (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 collector (Go to WS3)
[] 61 Tanker-truck (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)
[] 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 WS6)
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped into neighbour (Go to WS6)
[] 14 Public tap/standpipe
[] 12 Piped into compound, yard or plot (Go to WS6)
[] 13 Piped into neighbour (Go to WS6)
[] 14 Public tap/standpipe
[] 21 Tube well, borehole
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 collector
[] 61 Tanker-truck
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96 Other (specify) ____
[] 61 Tanker-truck
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96 Other (specify) ____
WS3. Where is that water source located?
[] 1 In own dwelling (Go to WS6)
[] 2 In own yard/plot (Go to WS6)
[] 3 Elsewhere
[] 2 In own yard/plot (Go to WS6)
[] 3 Elsewhere
WS4. How long does it take to go there, get water, and come back?
Number of minutes: _ _ _
[] 998 DK
[] 998 DK
WS5. Who usually goes to this source to collect the water for your household?
Probe: is this person under age 15? What sex?
[] 1 Adult woman (age 15+ years)
[] 2 Adult man (age 15+ years)
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK
[] 2 Adult man (age 15+ years)
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK
WS6. Do you do anything to the water to make it safer to drink?
[] 1 Yes
[] 2 No (Go to WS8)
[] 8 DK
[] 2 No (Go to WS8)
[] 8 DK
WS7. What do you usually do to make the water safer to drink?
Probe: 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
WS8. What kind of toilet facility do members of your household usually use?
If "flush" or "pour flush", probe: Where does it flush to?
If not possible to determine, ask permission to 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
Pit latrine
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab/open pit
[] 31 Composting toilet
[] 41 Bucket
[] 95 No facility, bush, field (Go to HH19)
[] 96 Other (specify) ____
[] 41 Bucket
[] 95 No facility, bush, field (Go to HH19)
[] 96 Other (specify) ____
WS9. Do you share this facility with others who are not members of your household?
[] 1 Yes
[] 2 No (Go to HH19)
[] 2 No (Go to HH19)
WS10. Do you share this facility only with members of other households that you know, or is the facility open to the use of the general public?
[] 1 Other households only (not public)
[] 2 Public facility (Go to HH19)
[] 2 Public facility (Go to HH19)
WS11. How many households in total use this toilet facility, including your own household?
Number of households (if less than 10): 0_
[] 10 Ten or more households
[] 98 DK
[] 10 Ten or more households
[] 98 DK
HH19. Record the time
Hours and minute____ ____
HH20. Thank the respondent for his/her cooperation and check the list of household members:
Check if there any woman age 15-49 eligible for questionnaire for individual women age 15-49 years in the household (HL7)
[] Yes, a separate questionnaire has been issued for each woman aged 15-49 years with the information panel filled in
[] No, there is no woman age 15-49
Check If there is any child under 5 eligible for questionnaire for children under five in the household (HL7B):[] No, there is no woman age 15-49
[] Yes, A separate questionnaire has been issued for each child under 5 with the information panel filled in.
[] No, there is no child under 5
[] No, there is no child under 5
Return to the cover page and make sure that the result of the household interview (HH9), the name and line number of the respondent to the household questionnaire (HH10), and the number of eligible women (HH12), men (HH13A), and under-5s (HH14) are entered. Make arrangements for the administration of the remaining questionnaire(s) in this household.
Interviewer's Observations ________
Field Editor's Observations ________
Supervisor's Observations ________