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 _ _ / _ _ / _ _ _ _

HH6. Area:

HH7. Region:

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.

HH16. Data entry clerk: _ _

Section 1 Characteristics of Household Member: 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)? How old was (name) in his/her last birthday?
Record in Completed years
HL5A. Citizenship

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?

HL8A. For adults age 18-59 years
Has (name) been very sick for atleast 3 months during the past 12 months?

Check HL5. Is there any child age age 0-17 ? If no, skip to section2

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

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

HL10A. For those that record 00 in HL10
Has (name's) mother been very sick for atleast 3 months during the past 12 months?

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

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

HL12A. For those that record 00 in HL12
Has (name's) father been very sick for atleast 3 months during the past 12 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

Section 2 Education: ED

For household members age 5 and above

ED1. Line no. _ _

ED1A. Name ____

ED2. Has (name) ever attended school or preschool?

ED3A. What is the highest level of school (name) attended?

ED3B. What is the highest grade completed? Record grade completed and type of certificate in detail. If (name) studies in university, teacher training, or vocational, record the highest level completed and the name of the institute attended before attending this level.

For household members age 5-24 years

ED4. During the (2005) school year, did (name) attend school or preschool at any time?

ED4A. Why (name) did not attend school?

ED5. Since last 7 days, how many days did (name) attend school?

ED6A. During this/that school year, which level is (name) attending?

ED6B. Which grade is (name) attending?

ED7. Did (name) attend school or preschool at any time during the previous school year, that is 2004?

ED8A. During that previous school year, which level did (name) attend?

ED8B. Which grade was (name) attending?

Orphan-hood Module

OV1.Check HL5: any children 0-17?

OV2. I would like you to think back over the past 12 months. Has any usual member of your household died in the past 12 months?

OV3. (Of those who died in the past 12 months) were any of them people between the ages of 18 and 59 Yrs?

OV4. (Of those who died in the past 12 months and were people between the ages of 18 and 59 Yrs) were any of them people seriously ill for 3. Of the 12 months before he/she died?

OV5. Return to the Household listing and check the following:

OV8. List all children aged 0-17 below. Record game, line numbers and ages of all children, beginning with the first child and continue in order in which listed in the household listing module. Use a continuation sheet if there are more than 4 children age 0-17 in the household. Ask all questions for one child before moving to the next child. .
1st child
Name (from HL2) ____
Line number (from HL1) __
Age (from HL5) __ __
2nd child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ __
3rd child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ __
4th child
Name (from HL2) ____
Line number (from HL1) __ __
Age (from HL5) __ _____ _

[Questions OV9 to OV20A are for all the children listed in OV8]
OV9. would like to ask you about any formal, organized help or support that your HH may have received for (Name) and for which you did not have to pay. By formal organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community-based. Remember this should be support for which you did not pay.
OV10. Now I would like to ask you about the support your HH received for (Name).
In the last 12 months, has your HH received any medical support for (Name), such as
medical care, supplies or medicine?

OV11. In the last 12 months, has your HH received any emotional or psychological support for
(Name), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home?

OV12. Did your HH receive any of this support in the past 3 months?

OV13. In the last 12 months, has your HH received any material support for (Name), such as
clothing, food or financial support?

OV14. Did your HH receive any of this support in the past 3 months?

OV15. In the last 12 months, has your HH received any social support for (Name), such as help
in HH work, training for a caregiver, or legal services?

OV16. Did your HH receive any of this support in the past 3 months?

OV17. Check OV8: Age of the child 5-17 yr?

OV18. In the last 12 months, has your HH received any support for (name's) schooling, such
as allowance, free admission, books or supplies?

OV19. Check HL3:

OV20. Length of stay of the child in this HH (Record in months):

OV20a. No. of previous homes/institutes where the child stayed before coming to this HH
(Exclude his/her parents' home)

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. Name: ____

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 ?

CL5. At any time during the past year, did (name) do any kind of work for those non-members 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? _ _

Disability: DA

DA3. Compared with other children, does (name) have any serious delay in sitting, standing, or walking?

DA4. Compared with other children, does (name) have difficulty seeing, either in the daytime or at night?

DA5. Does (name) appear to have difficulty hearing? (uses hearing aid, hears with difficulty, completely deaf?)

DA6. When you tell (name) to do something, does he/she seem to understand what you are saying?

DA7. Does (name) have difficulty in walking or moving his/her arms or does he/she have weakness and/or stiffness in the arms or legs?

DA8. Does (name) sometimes have fits, become rigid, or lose consciousness?

DA9. Does (name) learn to do things like other children his/her age?

DA10. Does (name) speak at all (can he/she make him or herself understood in words; can say any recognizable words)?

DA11. (For 3-9 year olds): Is (name)'s speech in any way different from normal (not clear enough to be understood by people other than the immediate family)?

DA12. (For 2-year-olds): Can (name) name at least one object (for example, an animal, a toy, a cup, a spoon)?

DA13. Compared with other children of the same age, does (name) appear in any way mentally backward, dull or slow?

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?

WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

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?

HC1D. Main occupation of Household (Max. income)

HC1E. Total income per month of all members

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. Type of stove used for food cooking( For code 05-11, 96 in HC6)

HC7A. The fire/stove have a chimney or a hood( For code 1-2 in HC7)

HC8. Where the cooking usually done?

HC9. Does your household have:








HC10. Does any member of your household own:







Salt iodization module: SI
Check whether the salt used un main cooking in household is iodized, and collect the sample of salt for lab test.

SI1. Result of I-Kit test

SI2. The package of salt when purchased
[] 1 In a bag, specified with iodized
[] 2 In a bottle, specified with iodized
[] 3 In a bag/bottle, not specified about iodized
[] 6 DK

SIA. Type of salt
[] 1 Coarse
[] 2 Refined

SIB. Record PPM from lab test
_ _ _ _ _ _