Province/City: _ _ _

District: _ _

Commune/ward: _ _

Location:

Cluster: _ _

Full name of household head: _ _

Interviewer: _ _

Date of interview: _ _ / _ _ / 2006

Supervisor: ________

Date of checking: _ _ / _ _ / 2006

Codes for ethnic groups

Part 1: Household Questionnaire: HH

HC1A. What is the religion of the household head?

HH1B. What is the mother tongue of the household head?
Interviewer record the code for mother tongue of household head in accordance with the respective code in the previous side page.
HH1B. What ethnic group does the household head belong to?
Refer to the table of ethnic groups
HH10. Respondent of household questionnaire? _ _

HH11. Total number of household members: _ _

HH12. Total number of women 15-49: _ _

HH13. Total number of women 15-49 completed interview(s): _ _

HH14. Total number of children under age 5: _ _

HH15. Total number of questionnaires for children under 5 completed: _ _

Notes:.

HH9. Result of interview

Household listing form: HL

First, please tell me the name of each household member, starting with the household head.
Use the given definition of member of household. List the head of the household in line 01 and record the listing in the sequence of each nuclear family. If there is not enough space for recording all household members in this sheet, add a continuation sheet, paste to this sheet and tick here []

HL1. Line no.: _ _

HL2. Name: ____

HL3. Relationship with household head
Refer to the table of codes in previous page
HL4. Sex?

HL5A. Date of birth?
In calendar year, month and day. (Record year in 4 digits). If do not know day, month and year, record 98/98/9998
HL5. How old is (name)?
Age in completed years
98 = DK*
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 children under 5: Who is the mother or primary caretaker of this child?

For children age 0-17 years ask HL9-HL12

HL9. Is the natural mother of (name) alive?

HL10. Who is the natural mother of (name)?
Record line number of corresponding natural mother. If natural mother does not live in this household, record 00
HL11. Is the natural father of (name) alive?

HL12. Who is the natural father of (name)?
Record line number of corresponding natural mother. If natural mother does not live in this household, record 00
Is there any other child living in this household, including who is not a member of your household or who is working far from home or is at school?
If yes, interviewer checks whether this child is a member of this household and add to the household listing (if any).

Education Module: ED

For household members age 5 and above

ED1. Line no. _ _

ED1A. Name ____

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

ED3. What is the highest grade that (name) completed?
Record grade. If has not completed Grade 1, record 00. DK, record 98
For household members age 5-24 years

ED4. During the 2006-2007 school year, did (name) attend school (including preschool)?

ED5. During the last 7 days, how many days did (name) attend school?
Record number of days. If in summer holiday, record 88.
ED6A. During school year 2006-2007, which level of school was or is (name) attending?

ED6B. During school year 2006-2007, which grade was or is (name) attending?
Record the grade. If DK, record 98.
ED7. During school year 2005-2006, did (name) attend school (including preschool)?

ED8A. During school year 2005-2006, which level of school was or is (name) attending?

ED8B. During school year 2005-2006, which grade was or is (name) attending?
Record the grade. If DK, record 98.
Non-standard: Non-standard curriculum includes illiteracy eradication classes, charity classes or other classes for primary school age children but the main purpose of such classes is to teach basic reading, writing, and simple maths.
Note for interviewer: If fieldwork is in August 2006, information for such questions as ED4, ED6A, and ED6B is of school year 2005-2006 and information for such questions ED7, ED8A, and ED8B is of school year 2004-2005.

Child labour module: CL

Respondent of this section is 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 7 days 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. During the past 7 days, 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?

CL5A. During the past 12 months, how many months did (name) do this work? _ _

CL5B. On average, how many days per month did (name) do this work? _ _

CL5C. On average, how many hours per day did (name) do this work? _ _

CL6. During the past 7 days, did (name) help with household chores such as cooking, washing clothes, fetching water, going to the market or looking after children, etc.?

CL7. During the past 7 days, how many hours did (name) spend doing these chores? _ _

CL8. During the last 7 days did (name) do any other family work (on the rice field or in a business or peddling in the street)

CL9. During the past 7 days, how many hours did (name) do this work? _ _

CL9A. During the last 7 days, did (name) do any other family work (on the rice field or in a business or peddling in the street)?
If yes, record months. If no, ask about next child Month.
CL9B. On average, how many days per month did (name) do this work? _ _

CL9C. On average, how many hours per day did (name) do this work? _ _

Water and sanitation module: WS

WS1. What is the main source of drinking water of your household?

WS2. What is the main source of water for other living purpose?

WS3. How many minutes does it take to go to this water source, wait, get water and return home?
Record with 3 digits.
WS4. Who usually goes to this water source to get the water?
Probe: Is this person under age 15? Boy or girl?

WS5. Do you have any treatment of the water before drinking (including boiling water)?

WS6. What treatment method have you used?
Any other method?
Circle all methods that have been used for water treatment.
WS7. What kind of latrine do members of your household use?
If "flush" or "pour flush", probe: Where do you flush/pour flush to?
Interviewer can ask to observe the latrine, if necessary.

WS8. Does your household share this latrine with other household(s)?

WS9. How many households share this latrine?

Dwelling and assets of the household: HC

HC1A. What is the religion of the household head?

HC1B. what is the mother tongue of the household head?
Interviews record the code for mother tongue of household head in accordance with the respective code in the previous side page.
_ _

HC2. How many rooms in your house/apartment can be used for sleeping?

HC2A. How many square meters in total is this house/apartment?

HC3. What is the main material of the floor:
Observe and interview.
HC4. What is the main material of the roof:
Observe and interview.
HC5. What is the main material of the walls:
Observe and interview.
HC6. What is the main cooking fuel of your household?

HC7. What kind is the stove/cooker usually used by your household for cooking?
Probe for the kind of stove/cooker.
HC7A. Does this stove have a chimney?

HC8. Is the cooking conducted in house, in a separate area or in the open air?

HC9. Does your household have:




















HC10. At present, does your household have land area, water surface area used for agricultural, forestry, aqua-cultural purposes?

HC11. How many meters of land area, water surface area used for agricultural, forestry, aqua-cultural purposes are under the management and use of your household?
If DK, record '9998'.
HC12. At present does your household raise any cattle and/or poultry?

HC13. How many of the following animals are in your household?

Treated Net: TN

TN1. Does your household have any mosquito nets?

TN2. How many mosquito nets does your household have?
If no, record 00. 1-6 nets record the exact number. 7 and more nets, record 8. DK, record 98.
TN2A. How many mosquito nets of your household have been treated with insecticide?
If no, record 00. DK record 98.
TN6. How many months ago was the (most recent) net treated with insecticide?
Below 1, record 00. From 1-23 months record the number of months. 24 months and more record 95. Do not remember record 98.
TN6A. Last night, how many members of your household sleep under the mosquito nets?
If no, record 00.
TN6B. Among those household members sleeping under mosquito nets, how many members sleep under insecticide treated nets?: _ _

Maternal mortality module: MM

This section is for all household members aged 15 and above (both male and female). Record name and line number of household members aged 15 and above. If anyone is not at home, other eligible adult household member can give proxy answer and record 2 in the answer box for MM3 and the line number of the person giving proxy answer in the answer box of MM4.

MM1. Line no.

MM2. Name

MM3. Is (name) directly answering or other member giving proxy answer?

MM4. Line number of person giving proxy answer

MM5. How many sisters (born to the same mother) has (name) had? (Including those who have died)
If none, record 00.
MM6. How many of these sisters have survived at the age of 15 and above (including those died after their 15th birthday)?
If none, record 00.
MM7. How many of these sisters (who are 15 years old or above) are alive now?

MM8. How many of these sisters (who reached the age of 15 years old or above) have died?
If none, record 00.
MM9. How many of these dead sisters died during pregnancy, birth delivery or within 6 weeks after delivery?

MM10. Of which how many persons died because of accident or could not say the reason why?

Child discipline module: CD

Table 1: List of children 2-14 years old
Interviewer to record the number of children 2-14 years old in the following table. Do not record household members who are not in the this age group

CD1. Ordering number.

CD2. Line no. of HH member taken from HL1.

CD3. Name from HL2.

CD4. Gender from HL4.

CD5. Age from HL5b.

CD6. Line no. of mother/primary 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, skip table 2 and record name, line number of this child and continue with question CD11.

Table 2: Random selection of a child for questions on forms of child punishment and discipline
The first column on the left indicates the last digit of the household number and the first row shows the total of eligible children (aged 2-14) of each household. Below are steps to randomly select a child for this section.
Step 1: Record necessary information of every eligible children in the household in the table 1.
Step 2: Use table 2 to select a child as follows:
CD8. Last digit of household number 0-9
Total number of eligible children aged 2-14 years old 1-8+
[Table omitted]

CD9. Record the line number of selected child

Identify the selected child aged 2 to 14 in the household using the tables in previous pages in accordance with the accompanying guideline. Interview the mother or primary caretaker of this child (record the line number of this mother/caretaker in column CD6).

CD11. Write name and line no. of the selected child from row CD9.

CD11A. During the last 4 weeks, has (name) made any error or had any wrong behavior?

CD12. During the last 4 weeks, when (name) made the error or had wrong behavior, did you or any adult in the household use the following methods with (name)

CD12A. Did not allow the child to do or enjoy the thing he/she likes or did not allow him/her to leave home.

CD12B. Explained the reason why the behavior is wrong.

CD12C. Grabbed the child angrily.

CD12D. Shouted at, scolded the child.

CD12E. Asked the child to do something that he/she did not like.

CD12F. Spanked on the bottom of the child with bare hand.

CD12G. Spanked, hit on the bottom of the child with belt, rod, or other hard object.

CD12H. Called the child such words as silly, lazy.

CD12I. Hit or slapped on the face, head or ear of the child with bare hand.

CD12J. Hit or spanked on the hand, arm or leg of the child with bare hand.

CD12K. Hit the child continuously with rod.

CD13. Do you think that, in order to raise the child properly, physical punishment is necessary?