We are from (country-specific affiliation). We are working on a project concerned with family health and education. I would like to talk to you about this. The interview will take about (number) minutes. 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. Cluster number: _ _ _

HH2. Household Number _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

HH5. Day/month/year of interview _ _ / _ _ / 2006

HH6. Area:

HH7. Region: ______

HH7A. Prefecture _____

HH7B. City/Village ______

HH8. Name of head of household: ____

After all questionnaires for the household have been completed, fill in the following information:
[Note: HH9 to HH16]

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.

HH16A. Controller

HH16B. Supervisor

HH16C. Office Controller

HH16D. Entered by

Module 1: 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 are more than 15 household members.
[] 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 5-14: 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. Was (name) very sick for at least three months out of the past twelve months?

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?

HL10A. If the mother does not live in the household: Has (name)'s mother been very sick for at least three months of the last twelve months?

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

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

HL12A. If the father does not live in the household: Has (name)'s natural father been very sick for at least three months of the last twelve 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. Family name and first name _____

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 (2005-2006) 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?

ED5A. During the school year (2005-2006), did (name) habitually attend school?

ED6. During this/that school year (2005-2006), 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?

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

Module 4: Household characteristics module: HC

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

HC1B. What is the mother tongue/native language of the head of this household?

HC1C. To what ethnic group does the head of this household belong?

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 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:







HC11. Does any member of this household own any land that can be used for agriculture?
[This question is from optional modules]

HC12. How many hectares of agricultural land do members of this household own?
[This question is from optional modules]
If more than 97, record '97'. If unknown, record '98'.
HC13. Does this household own any livestock, herds, or farm animals?
[This question is from optional modules]
HC14. How many of the following animals does this household have?
[This question is from optional modules]






[IPUMS: Description is from optional modules]
Countries may add to the list of items in HC9 items of furniture (such as a table, a chair, a sofa, a bed, an armoire, or a cupboard or cabinet). In addition, each country should add at least four additional household appliances so that the list includes at least three items that even a poor household may have, at least three items that a middle income household may have, and at least three items that a high income household may have. Some possible additions are clock, water pump, grain grinder, fan, blender, water heater, electric generator, washing machine, microwave oven, computer, VCR or DVD player, cassette or CD player, camera, air conditioner or cooler, color TV, sewing machine.
Countries may add other country-specific animals, such as oxen, water buffalo, camels, llamas, alpacas, pigs, ducks, geese, or elephants to the list in HC14.

HC15A. Do you or someone in this household own this dwelling, or do you rent this dwelling?

HC15B. Do you or someone in this household have a title deed for this dwelling?

HC15C. What kind of document do you have for the ownership of this dwelling?
Anything else?
Record all items mentioned.
HC15D. Do you have a written rental contract for this dwelling?

HC15E. Do you have any documentation or agreement for the rental of this dwelling? If yes, what kind of document or agreement do you have for the rental of this dwelling? Anything else?
Record all items mentioned.
HC15F. Do you feel secure from eviction from this dwelling?

HC15G. Have you been evicted from your home at any time during the past 5 years?

HC15H. Dwelling located in or near:
Observe, and circle all items that describe the location of dwelling.
HC15I. Condition of dwelling:
Record observation. Record all that apply.
HC15J. Dwelling surroundings:
Record observation. Record all that apply.
Module 5: Insecticide-Treated Mosquito Netting (ITN)

TN1. In your household, do you have mosquito nets that can be used for sleeping?

TN2. How many mosquito nets do you have in your household?
If more than 7, record 7.
TN2A. How many mosquito nets do you use for sleeping?
If more than 7, record 7.
TN3. Are your mosquito nets any of the following brands?
Read the name of each brand, show the image, and circle the corresponding code. Yes or no for each brand. If possible, ask the respondent to show you the net to double check the brand..









TN3A. Where did you get the (name of net highest in the list of nets available in the household, in TN3) mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than one net in the same category, ask question referring to the most recently obtained net.
TN3B. How much did you pay for the (name of net highest in the list of nets available in the household, in TN3) mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than one net in the same category, ask question referring to the most recently obtained net.
TN4. Check TN3 for the brand of net(s). Review the list at the top in order until a box is checked, and follow the instructions below
TN5. When you got the (most recent) net, was it treated or re(impregnated) with when you got the (most recent) net, was it treated or re(treated) with an insecticide to kill or keep mosquitoes away?

TN6. How long have you owned the (more recent) mosquito net?
If less than 1 month, write '00'. If the answer is "12 months" or "1 year", insist to determine if the net has been obtained, it is exactly 12 months ago or earlier or later.
TN7. Since you have the net(s), do you have it (had it) soaked(s) or dived(s) in a liquid to kill/repel mosquitoes?

TN8. How many months have you been soaking it in a liquid??
If less than 1 month, write '00'. If the answer is "12 months" or "1 year", insist to determine if the net has been obtained, it is exactly 12 months ago or earlier or later.
Module 6: Children Made Vulnerable and Orphaned by AIDS (OV)

OV1. Verify HL5: Are there any children aged 0-17?
OV2. I would like you to think about the last 12 months. Did a member of your household pass away in the last twelve months?

OV3. For those who passed away in the last 12 months, were any of them between 18-59 years old?

OV4. For those who passed away in the last 12 months and were aged 18-59 years old: were any of them extremely sick for at least 3 months of the 12 months prior to their death?

OV5. Return to the HH table and check the following:
OV8. List all children ages 0-17. Record the names, line numbers, and ages of all children,
starting with the first child, and continue in the order in which they are listed in the
household registration module. Use an additional questionnaire if there are more than 4 children aged 0-17 in the household. Ask any questions for one child before moving on to the next child.

OV9. I would like to ask you about any type of assistance or organized support your household may have received for (name) for which you did not pay for. By organized help or support, I meansupport provided by someone who works for a program, whether it be government
private sector, religious, charitable or community-based program. It is important to
remember that this is support for which you have not paid.
[The answers for OV10-OV18 are all a continuation of children table 1-5 as listed in question above.]

OV10. I would like to ask you questions about the support your household has received for (name). In the past 12 month, did your household months, has your household received medical support for (name), such as care, supplies or medicines?

OV11. In the last 12 months, did your household receive moral or psychological support for (name) such as companionship, advice from a counselor, counseling, or spiritual support?

OV12. Did your household receive any type of these supports in the last 3 months? 

OV13. In the last 12 months, did your house receive any material support for (name) such as clothes, food, or financial support? 

OV14. Did your household receive any type of these supports in the last 3 months?

OV15. In the last 12 months, did your household receive social support for (name) such as help around the house, training to provide caregiving or assistance for administrative procedures?

OV16. Did your household receive any type of these supports in the last 3 months?

OV17. Verify OV8, the age of the child.
OV18. In the last 12 months, did your household receive support for schooling from (name) as a scholarship, free tuition, books or supplies?

Module 7: Child labour module: CL

To be administered to mother/caretaker of each child in the household age 5 through 14 years. For household members below age 5 or above age 14, leave rows blank.
Now I would like to ask about any work children in this household may do.

CL1. Line no. _ _

CL2. Family name and first names: ____

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?

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? _ _

Module 8:Child discipline module: CD

Table 1: Children aged 2-14 years eligible for child discipline questions
Review the household listing and list each of the children aged 2-14 years below in order according to their line number (HL1). Do not include other household members outside of the age range 2-14 years. Record the line number, name, sex, age, and the line number of the mother or caretaker for each child. Then record the total number of children aged 2-14 in the box provided (CD7).

CD1. Rank 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 _ _

If there is only one child age 2-14 years in the household, then skip table 2 and go to CD9; write down the rank number of the child and continue with CD11

Table 2: Selection of random child for child discipline questions
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 CD12.

CD8. Last digit of the questionnaire number 0-9
Total number of eligible children in the household 1-8+
[Table omitted]

CD9. Record the rank number of the selected child

Identify eligible child aged 2 to 14 in the household using the tables on the preceding page, according to your instructions. Ask to interview the mother or primary caretaker of the selected child (identified by the line number in CD6).

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?

Module 9: 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 to 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 to administer the questionnaire to mother or 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.)