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 (30**) 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 _ _ / _ _ / _ _ _ _

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.

HH16A. Name and code of editor:

Date of editing and signature:

HH16. Data entry clerk: _ _

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

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?

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. 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?

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 (2004-2005)?

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?
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

Household characteristics module: HC

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

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/have any land that can be used for agriculture?

HC12. How many hectares of agricultural land do members of this household own?
If1 and more than circle '1' and record amount of hectares. If more than 97, record '97'. If less than 1 hectare, circle '2' and record amount of hundredth parts. If unknown, record '998'.
HC13. Does this household own any livestock, herds, or farm animals?

HC14. How many of the following animals does this household have?

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 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? _ _

Disability: DA

To be administered to caretakers of all children 2 through 9 years old living in the household. For household members below age 2 or above age 9, leave rows blank
I would like to ask you if any children in this household aged 2 through 9 has any of the health conditions I am going to mention to you.

DA1. Line no.

DA2. Child's name

DA3. Compared with other children, does or did (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?

Maternal mortality module: MM

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. Indicate this by placing a '1' in MM3, and insert line number of proxy respondent in MM4. 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?

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.)