Household Questionnaire

[Togo]
Household Information Panel: HH

HH1. Cluster number: _ _ _

HH2. Household number:

HH2A. Household selected for Questionnaire for Individual Man

HH3. Interviewer name and number

HH4. Field editor's name and number:

HH5. Day/month/year of interview

HH6. Area

HH7. Region: ______ _

HH7A. Prefecture: ______ _ _

HH7B. City / Canton: ______ _ _

We are from the National Office of Statistics and Accounting. We are working on a project concerned with family health and education. I would like to talk to you about these subjects. The interview will take several minutes. All the information we obtain will remain strictly confidential and your answers will never be shared with anyone other than our project team. May I start now?

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

HH8. Name of head of household: ____

HH9. Result of household interview:

HH10. Respondent to household questionnaire:

HH11. Total number of household members: _ _

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

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

HH14. Number of children under age 5: _ _

HH15. Number of under-5 questionnaires completed: _ _

HH15A. Number of men age 15-59 years: _ _

HH15B. Number of men's questionnaires completed: _ _

HH16. Field edited by (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. Line number: _ _

HL2. Name: ____

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

HL4. Is (name) male or female?

HL5. What is (name's) date of birth?

HL6. How old is (name)?
Probe: How old was (name) on his/her last birthday? Record in completed years. If age is 95 or above '95'
Age: _ _

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

HL7A. Circle line no.
If man is age 15-59 (for men age 15-59)

HL8. For children age 5-14 years: Who is the mother or primary caretaker of this child?
Record line no. of mother/caretaker (for children age 5-14.)
HL9. For children under age 5: 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 all household members)
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"

text id="43">
[] 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 employees, 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 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. For each man age 15-59 years, write his name and line number and other identifying information in the information panel of a separate individual man's questionnaire. You should now have a separate questionnaire for each eligible woman, each child under five in the household and for each eligible man.

Code for HL3. Relationship to head of household

Education: ED

For household member age 3 and above [ED1 to ED4]

ED1. Line number: _ _

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

ED4. What is the highest level of school (name) has attended? What is the highest grade (name) completed at this level?
If level=0, skip to ED5. If less than 1 grade, enter 00.
For household members age 3-24 years [ED5 to ED8]

ED5. During the (2010-2011) school year, did (name) attend school or kindergarten at any time?

ED6. During the 2010-2011 school year, which level and grade is/was (name) attending?
If level=0, skip to ED7

[] 0 Kindergarten
[] 1 Primary
[] 2 Middle School
[] 3 High School
[] 4 Higher
[] 8 DK

ED6C. During the 2009-2010 school year, what type of school was (name) attending?

ED7. During the previous school year, that is (2009-2010), did (name) attend school or kindergarten at any time?
Go to ED9 if ED5=1, otherwise, go to next line
ED8. During that previous school year (2009-2010), which level and grade did (name) attend?
If level=0, skip to ED9 if ED5=1, otherwise, go to the next person
ED9. During the 2009-2010 school year how much did you spend on school fees and parallel funds, school supplies and school uniforms for (name)?

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?

WS3. Where is that water source located?

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

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 can anyone use these toilets?

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

WS12. In your household do you use garbage bins made out of:

[A] Plastic

[B] Metal

[C] Palm branch basket

[D] Bags

[E] Other (Specify) ______

[F] No garbage recipient

WS13. Do you sort your different trash (non-degradable objects, glass fragments, and others) before placing it in the waste bins?

WS14. Do you pay for a pre-collection service or communal service?

WS15. How many times a week is trash collected?
Record the number of times per week, if more than 7, record 7.
WS16. What is the monthly cost for this service in CFA francs?

WS17. Where do you mainly throw your trash?

Household characteristics: 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 dwelling floor
Record main 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 stovetop or cooker?

G. A generator?

H. An air conditioner?

I. A solar panel?

HC9. Does any member of your household own:

A. A watch?

B. A mobile telephone?

C. A bicycle?

D. A moped 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 "3", "4" or "6", as needed.
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, or poultry?

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?

B. Horses, donkeys, or mules?

C. Goats?

D. Sheep?

E. Chickens?

F. Pigs?

G. Guinea fowl?

H. Ducks?

HC15. Does any member of this household have a bank account or an account in a microfinance institution?

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?

TN3. Ask the respondent to show you the nets in the household. If more than 3 nets, use additional questionnaire(s).
[Repeat questions from modules TN4-TN13 for each net]

TN4. Mosquito net observed?

TN5. Observe or ask the brand/type of mosquito net.
If brand is unknown and you cannot observe the net, show pictures of typical net types/brands to respondent.
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
TN8. When you got the net, was it already treated with an insecticide to kill or repel mosquitoes?

TN9. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

TN10. How many months ago was the net last soaked or dipped?
If less than one month, record "00"
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
TN13.
1st Net: Go back to TN4 for next net. If no more nets, go to next module.
2nd Net: Go back to TN4 for next net. If no more nets, go to next module.
3rd Net: Go back to TN4 in first column of a new questionnaire for next net. If no more nets, go to next module.
Child Labour: CL

To be administered for children in the household age 5-14 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 number: _ _

CL2. Name and age copy from Household Listing Form, HL2 and HL6

CL3. During the past week, 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?
CL4. 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?
If more than one job, include all hours at all jobs.
CL5. During the past week, did (name) fetch water or collect firewood for household use?

CL6. Since last (day of the week), about how many hours did he/she fetch water or collect firewood for household use?

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.
CL8. Since last (day of the week), about how many hours did he/she do this work for his/her family or himself/herself?

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?

CL10. Since last (day of the week), about how many hours did he/she spend doing these chores?

Child Discipline: CD

Table 1: Children Aged 2-14 Years Eligible for Child Discipline Questions
List each of the children aged 2-14 years below in the order they appear in the household listing form. Do not include other household members outside of the age range 2-14 years.
Record the line number, name, sex, and age for each child.
Then record the total number of children aged 2-14 in the box provided (CD6).
If there is only one child age 2-14 years in the household, then skip table 2 and go to CD8; write down '1' and continue with CD9.

CD1. Rank Number: _

CD2. Line number from HL1: _ _

CD3. Name from HL2: ____

CD4. Sex from HL4

CD5. Age from HL6: _ _

CD6. Total children age 2-14 years: _ _

Table 2:Random Selection of Child for Child Discipline Questions
Use Table 2 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.
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 eligible children (age 2-14) in CD6 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 (CD1) about whom the questions will be asked.

CD7.
Total number of eligible children in the household (CD6) [Column 1 to 8+]
Last digit of household number (HH2) [Row 0 to 9]
CD8. Record the rank number of the selected child: _

CD9. Write the name and line number of the child selected for the module from CD3 and CD2, based on the rank number in CD8.
CD10. 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.

CD11. Took away privileges, forbade something (name) liked or did not allow him/her to leave house.

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

CD13. Shook him/her.

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

CD15. Gave him/her something else to do.

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

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

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

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

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

CD21. Beat him/her up, that is hit him/her over and over as hard as possible.

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

Hand washing: HW

HW2. Observe presence of water at the specific place for handwashing.
Verify by checking the tap/pump, or basin, bucket, water container or similar objects for presence of water.
HW3. Record if soap or detergent is present at the specific place for handwashing.
Circle all that apply.
HW4. Do you have any soap or detergent (or other locally used cleansing agent) in your household for washing hands?

HW5. Can you please show it to me?
Record observation. Circle all that apply.
HH19. Record the time of end of interview

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.
HH20. Are there any eligible women age 15-49 living in the household?
Check the household list column HL7 for each eligible woman. You should have a questionnaire with a completed information panel for each eligible woman.
HH21. Are there any children under age 5 living in the household?
Check the household list column HL9 for each eligible child under age 5. You should have a questionnaire with completed information panel for each eligible child.
HH22. Is household eligible for Man's survey?

Gather up all the questionnaires for this household and record the number of completed questionnaires on cover page.

Interviewer's observations ________

Field editor's observations ________

Supervisor's observations ______