MICS Household Questionnaire

South Sudan
Household Information Panel: HH

HH1. Code: _ _ _

HH2. Household number: _ _

HH3. Interviewer name and number

HH4. Supervisor name and number:

HH5. Day/month/year of interview

HH6. Area

HH7. Location

We are from Sudan Household Health Survey 2nd round which is concerned with family health and socioeconomic indicators. I would like to talk to you about these subjects. The interview will take about (45 minutes). All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team. During this time, I would like to speak with the household head and all mothers or other who take care of children in the household. May I start now?

After all questionnaires for the household have been completed, fill in the following information:
[Note: for question HH8 to HH18]

HH8. Name of household: ____

HH9. Result of household interview:

HH10. Respondent to HH questionnaire:

HH11. Total number of household members: _ _

HH12. Number of women age 15-49 years: _ _

HH13. Number of woman's questionnaires completed: _ _

HH13a. Number of men age 15-49 years: _ _

HH13B. Number of men's questionnaires completed: _ _


HH14. Number of children under age 5: _ _

HH15. Number of child questionnaires completed: _ _

HH16. Field edited name and number

HH17. Date entry clerk name and number

HH18. Record the time

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?
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. Home-hold Line number: _ _

HL2. Name: ____

HL3. What is the relation-ship of (name) to the head of household?

Code for HL3. Relationship to head of household

HL4. Is the (name) male or female?

HL6. How old was (name) on his/her last birthday?
Record in completed years. If age is 956 or above '956'
HL6A. What is the marital status of (name)?

HL7. Circle line no.
If woman is age 15-49 (for woman age 15-49)

HL7A. Circle line no.
If man is age 15-49 (for men age 15-49)

HL9. Who is the mother or primary caretaker of this child?
Record line no. of mother/ caretaker (for children under age 5)
HL10. Did (name) stay here last night?

For children age 0-17 years [HL11 to HL14]

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

HL12. Does (name's) natural mother live in this household?
Record line number of number or 00 for no
HL13. Is (name's) natural father alive?

HL14. Does (name's) natural father live in this household?
Record line no. of father or 00 for "no"
HL15. How has (name) spent (his/her)time during the past 3 months? Was (name):

HL10. Is child is 2-9 years

[] tick here is additional questionnaire 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.

Education: ED

For household member age 5 and above [ED1 to ED4B]

ED0. Can this person read and write in any language?
Copy from Household Listing Form, HL2 and HL6
ED1. Line number: _ _

ED2. Name and age
Copy from Household Listing Form, HL2 and HL6
ED3. Has (name) ever attended school or pre-school?

ED4: What is the highest level of school (name) has attended?
If level=0, skip to ED5
ED4B. What is the highest grade (name) completed at this level?
If less than 1 grade, enter 00
For household members age 5-24 years [ED5 to ED8]

ED5. During the (2009-2010) school year, did (name) attend school or preschool at any time?

ED6. During this/that school year, which level and grade is/was (name) attending?
If level=0, skip to ED5
ED7. During the previous school year, that is (2008-2009), did (name) attend school or preschool at any time?

ED8. During that previous school year (2008-2009), which level and grade did (name) attend?
If level=0, skip to ED5
Water and Sanitation: 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?

WS4. By foot, How long does it take to go there, get water, and come back?

WS4A. What's the distance to the water source from your residence?

WS5. Who usually goes to this source to collect the water for your household?
Probe: Is this person under age 15? What sex?

WS6. Do you do anything to the water to make it safer to drink?

WS7. What do you usually do to make the water safer to drink?
Probe: Anything else? Record all items mentioned.
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 necessary, ask permission to observe the facility.
WS9. Do you share this facility with others who are not members of your household?

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?

WS11. How many households in total use this toilet facility, including your own household?

WS11A. What do you do to get rid of household garbage?

Household characteristics: HC

HC0. How many rooms/verandas/tukuls belong to this household?

HC2. How many rooms/verandas/tukuls are used for sleeping?

HC2a. What type of dwelling does this household live in?

HC3. Main material of dwelling floor
Record observation
HC4. Main material of the roof
Record observations
HC5. Main material of the exterior walls.
Record observations
HC6. What type of fuel does your household mainly use for cooking?

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?

HC8. Does your household have:

A. Electricity?

B. A radio?

C. A television?

D. A non-mobile telephone?

E. A refrigerator?

F. A computer?

G. Internet?

H. Digital receiver?

HC9. Does any member of your household own:

A. A watch?

B. A mobile telephone?

C. A bicycle?

D. A motorcycle or scooter?

E. An animal drawn cart?

F. A car or truck?

G. A boat with a motor?

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".
HC11. Does any member of this household own any land that can be used for agriculture?

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'.
HC13. Does this household own any livestock, herds, other farm animals?

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?

C. Goats?

D. Sheep?

E. Chickens, pigeons and ducks?

HC14a. 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. Milk cows?

B. Horses, donkeys, or mules?

C. Camels?

F. Pigs?

Insecticide Treated Nets: TN

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

TN2. How many mosquito nets does your household have?

TN6. How many months ago did your household get the mosquito net?
If less than one month, record "00"
TN7. Check TN5 for type of net
TN11. Did anyone sleep under this mosquito net last night?

TN12. Who slept under this mosquito net last night?
Record the person's line number from the household listing form
If someone not in the household list slept under the mosquito net, record 00
HH19. Record the time

Salt Iodization: SI
SI1. We would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?
Once you have tested the salt, circle number that corresponds to test outcome.
SI2. Where did you acquire this salt?

HH20. Thank the respondent for his/her cooperation and check the Household Listing Form Does any eligible woman age 15-49 reside in the household?

HH21. Does any child under the age of 5 reside in the household? Check household listing, column HL9. You should have a question with the Information Panel filled in for each eligible child.

HH21A. Does any eligible man age 15-49 reside in the household? Check household listing, column HL7A for any eligible man. You should have a question with the Information Panel filled in for each eligible man.

Interviewer's observations ________

Field editor's observations ________