Household Information Panel: HH

HH1. Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer name:

HH4. Supervisor name:

HH4A. Head of group name:

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

HH6. Area:

HH7. Governorate

HH7A. Area Name

HH7B. City/Village _ _ _ _

HH8. Name of head of household: ____

HH9. Result of interview:

HH10. Respondent to 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: _ _

HH16. Data entry clerk name:
Code _ _

HH16A. Coding clerk name

HH16B. Editor name

Comments:

Household listing form: HL

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)?
Record in Completed years
HL6. Eligible for women's interview

HL7. Eligible for child labour module
For each child age 5-14:

HL8. Eligible for under-5 interview
For each child under 5:

For children age 0-17 years ask HL9-HL12

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

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

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

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

Totals

In case the number of household members exceeded /12/, put (X) in the square, use the next page and modify the numbers

Education Module: ED

For household members age 5 and above

ED1. Line no. _ _

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. Does (name) attend school for the current school year 2005-2006?

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 (2004-2005)?

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?

WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

Household characteristics module: HC

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 dwelling floor.
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.
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:








Child labour module: CL

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?

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: During 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? _ _

Child discipline module: CD

Table 1: Children aged 2-14 years eligible for child discipline questions
Check HL and identify eligible child aged 2 -14 in the household consequently according to their line number. Do not include other member outside the age 2-14. Record line number,
name, sex, age, and mother's/care giver's line number for each child..

CD1. No.

CD2. Line no. from HL1.

CD3. Name from HL2.

CD4. Sex from HL4.

CD5. Age from HL5.

CD6. Line no. of mother/caretaker from HL7 or HL8.

CD7. Total children aged 2-14 years _ _

In case there is one child from 2-14 year move to CD11

Table 2: Selection of random child for child discipline questions
CD8. Use this table to select one child between the ages of 2 and 14 years, if there is more than one child in that age range in the household. Look for the last digit of the household number from the cover page. This is the number of the row you should go to in the table below. Check the total number of eligible children (2-14) in CD7 above. This is the number of the column you should go to. Find the box where the row and the column meet and circle the number that appears in the box. This is the rank number of the child about whom the questions will be asked. Record the rank number in CD9 below. Finally, record the line number and name of the selected child in CD11 on the next page. Then, find the mother or primary caretaker of that child, and ask the questions, beginning with CD11.

CD9. Record the rank number of the selected child from CD8.

CD11. Write name and line no. of the child selected for the module from CD3 and CD2, based on the rank number in CD9.

CD12. All adults use certain ways to teach children the right behaviour or to address a behaviour problem. I will read various methods that are used and I want you to tell me if you or anyone else in your household has used this method with (name) in the past month.

CD12A. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

CD12B. Explained why something (the behavior) was wrong.

CD12C. Shook him/her.

CD12D. Shouted, yelled at or screamed at him/her.

CD12E. Gave him/her something else to do.

CD12F. Spanked, hit or slapped him/her on the bottom with bare hand.

CD12G. Hit him/her on the bottom or elsewhere on the body with something like a belt, hairbrush, stick or other hard object.

CD12H. Called him/her dumb, lazy, or another name like that.

CD12I. Hit or slapped him/her on the face, head or ears.

CD12J. Hit or slapped him/her on the hand, arm, or leg.

CD12K. Beat him/her up with an implement (hit over and over as hard as one could).

CD13. Do you believe that in order to bring up (raise, educate) (name) properly, you need to physically punish him/her?

MATERNAL MORTALITY MODULE
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. 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?

MM6. How many of these sisters ever reached age 15?

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?

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