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MICS household questionnaire


We are from Ministry of Health. 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 60 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:

Name: ____
Number: _ _

HH4. Supervisor name and number:

Name: ____
Number: _ _

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

HH6. Area:

[] 1 Urban
[] 2 Rural

HH7. Region/Province:

[] 1 Tafea
[] 2 Shefa
[] 3 Malampa
[] 4 Penama
[] 5 Sanma
[] 6 Torba
[] 7 Port Vila
[] 8 Luganville

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:

[] 1 Completed
[] 2 Not at home
[] 3 Refused
[] 4 HH not found/destroyed
[] 6 Other (specify) ____

HH10. Respondent to HH questionnaire

Name: ____
Line No: _ _

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: _ _

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?

[] 01 Head
[] 02 Wife or husband
[] 03 Son or daughter
[] 04 Son or daughter in-law
[] 05 Grandchild
[] 06 Parent
[] 07 Parent-in-law
[] 08 Brother or sister /step brother
[] 09 Brother or sister-in-law
[] 10 Uncle/aunt
[] 11 Niece/nephew by blood
[] 12 Niece/nephew by marriage
[] 13 Other relative
[] 14 Adopted/foster/stepchild
[] 15 Not Related
[] 98 Don't know

HL4. Is (name) male or female?

[] 1 Male
[] 2 Female

HL5. How old is (name)? How old was (name) in his/her last birthday?
Record in Completed years
Age: _ _
[] 98 DK [See instructions: to be used only for elderly household members (code meaning "do not know/over age 50").]

HL6. Eligible for women's interview

_ _Circle line no. if woman is age 15-49

HL8. Eligible for under-5 interview
For each child under 5: Who is the mother or primary caretaker of this child

_ _ Record line no. of mother/caretaker

For children age 0-17 years ask HL9-HL12

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

[] 1 Yes
[] 2 No (Go to HL11)
[] 8 DK (Go to HL11)

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

_ _ Record line no. of mother or 00 for 'no'

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

[] 1 Yes
[] 2 No (Go to next line)
[] 8 DK (Go to next line)

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

_ _ Record line no. of father or 00 for 'no'

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

_ _ Women 15-49
_ _ Under-5s

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?

[] 1 Yes (Go to ED3)
[] 2 No (Go to next line)

ED3. What is the highest level of school (name) attended? What is the highest grade (name) completed at this level?

Level:
[] 0 Pre-school
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Vocational schools/rural training center
[] 8 DK
Grade: _ _
[] 98 DK
If less than 1 grade, enter 00.

For household members age 5-24 years

ED4. During the 2007 school year, did (name) attend school or preschool at any time?

[] 1 Yes
[] 2 No (Go to ED7)

ED5. Since last (day of the week), how many days did (name) attend school?

_ Insert number of days in space below

ED6. During this school year, which level and grade is/was (name) attending?

Level:
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Vocational schools/rural training center
[] 8 DK
Grade: _ _
[] 98 DK

ED7. Did (name) attend school or preschool at any time during the previous school year, that is 2006?

[] 1 Yes
[] 2 No (Go to next line)
[] 8 No (Go to next line)

ED8. During that previous school year, which level and grade did (name) attend?

Level:
[] 0 Preschool
[] 1 Primary
[] 2 Secondary
[] 3 Higher
[] 6 Vocational schools/rural training center
[] 8 DK
Grade: _ _
[] 98 DK

Water and sanitation module: WS

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

Piped water
[] 11 Piped into dwelling (Go to WS5)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe (Go to WS3)
[] 21 Tubewell/borehole (Go to WS3)
Dug well
[] 31 Protected well (Go to WS3)
[] 32 Unprotected well (Go to WS3)
Water from spring
[] 41 Protected spring (Go to WS3)
[] 42 Unprotected spring (Go to WS3)
[] 51 Rainwater collection (Go to WS3)
[] 61 Tanker-truck (Go to WS3)
[] 71 Cart with small tank/drum (Go to WS3)
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel) (Go to WS3)
[] 91 Bottled water
[] 96 Other (specify) ____ (Go to WS3)

WS2. What is the main source of water used by your household for other purposes such as cooking and handwashing?

Piped water
[] 11 Piped into dwelling (Go to WS5)
[] 12 Piped into yard or plot (Go to WS5)
[] 13 Public tap/standpipe
[] 21 Tubewell/borehole
Dug well
[] 31 Protected well
[] 32 Unprotected well
Water from spring
[] 41 Protected spring
[] 42 Unprotected spring
[] 51 Rainwater collection
[] 81 Surface water (river, stream, dam, lake, pond, canal, irrigation channel)
[] 96 Other (specify) ____

WS3. How long does it take to go there, get water, and come back?

_ _ _ No. of minutes
[] 995 Water on premises (Go to WS5)
[] 998 DK

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.

[] 1 Adult woman
[] 2 Adult man
[] 3 Female child (under 15)
[] 4 Male child (under 15)
[] 8 DK

WS5. Do you treat your water in any way to make it safer to drink?

[] 1 Yes
[] 2 No (Go to WS7)
[] 8 DK (Go to WS7)

WS6. What do you usually do to the water to make it safer to drink?
Anything else?
Record all items mentioned.
[] A Boil
[] B Add bleach/chlorine
[] C Strain it through a cloth
[] D Use water filter (ceramic, sand, composite, etc.)
[] E Solar disinfection
[] F Let it stand and settle
[] X Other (specify) ____
[] Z DK

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.

Flush/pour flush
[] 11 Flush to piped sewer system
[] 12 Flush to septic tank
[] 13 Flush to pit (latrine)
[] 14 Flush to somewhere else
[] 15 Flush to unknown place/not sure/DK where
[] 21 Ventilated improved pit latrine (VIP)
[] 22 Pit latrine with slab
[] 23 Pit latrine without slab / open pit
[] 51 Hanging toilet/hanging latrine
[] 95 No facilities or bush or field (Go to next module)
[] 96 Other (specify) ____

WS8. Do you share this facility with other households?

[] 1 Yes
[] 2 No (Go to next module)

WS9. How many households in total use this toilet facility

0_ No. of households (if less than 10)
[] 10 Ten or more households
[] 98 DK

Household characteristics module: HC

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

[] 1 Christianity
[] 2 Muslim/ Islam
[] 3 Kustom
[] 6 Other religion (specify) ____
[] 7 No religion

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

[] 1 Bislama
[] 6 Other language (specify) ____

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

[] 1 Melanesian
[] 2 Polinesian
[] 3 Micronesian
[] 4 Caucasian
[] 6 Other ethnic group (specify) ____

HC1D. For how long the members of this household are living in this area?

No. of years: _ _

HC2. How many rooms in this household are used for sleeping?

No. of rooms: _ _

HC3. Main material of the dwelling floor:
Record observation.
Natural floor
[] 11 Earth/sand
[] 13 Coral
Rudimentary floor
[] 21 Wood planks
[] 22 Palm/bamboo
Finished floor
[] 31 Parquet or polished wood
[] 32 Vinyl or asphalt strips
[] 33 Ceramic tiles
[] 34 Cement
[] 35 Carpet
[] 36 Mat
[] 96 Other (specify) ____

HC4. Main material of the roof.
Record observation.
Natural roofing
[] 11 No roof
[] 12 Thatch/palm leaf
[] 13 Sod
Rudimentary roofing
[] 21 Rustic mat
[] 22 Palm/bamboo
[] 23 Wood planks
Finished roofing
[] 31 Metal
[] 32 Wood
[] 33 Calamine/cement fiber
[] 34 Ceramic tiles
[] 35 Cement
[] 96 Other (specify) ____

HC5. Main material of the walls.
Record observation.
Natural walls
[] 11 No walls
[] 12 Cane/palm/trunks
[] 13 Dirt
[] 14 Coconut Leaves/thatches
[] 15 Bamboo
Rudimentary walls
[] 21 Bamboo with mud
[] 22 Stone with mud
[] 24 Plywood
[] 25 Carton
[] 26 Reused wood
Finished walls
[] 31 Cement
[] 32 Stone with lime/cement
[] 33 Bricks
[] 34 Cement blocks
[] 36 Wood planks/shingles
[] 96 Other (specify) ____

HC6. What type of fuel does your household mainly use for cooking?

[] 01 Electricity (Go to HC8)
[] 02 Liquid propane gas (LPG) (Go to HC8)
[] 05 Kerosene
[] 06 Coal/lignite
[] 07 Charcoal
[] 08 Wood
[] 09 Straw/shrubs/grass
[] 96 Other (specify) ____

HC7. In this household, is food cooked on an open fire, an open stove or a closed stove?
Probe for type.
[] 1 Open fire
[] 2 Open stove
[] 3 Closed stove (Go to HC8)
[] 6 Other (specify) ____ (Go to HC8)

HC7A. Does the fire/stove have a chimney or a hood?

[] 1 Yes
[] 2 No

HC8. Is the cooking usually done in the house, in a separate building, or outdoors?

[] 1 In the house
[] 2 In a separate building
[] 3 Outdoors
[] 6 Other (specify) ____

HC9. Does your household have:

Electricity?
[] 1 Yes
[] 2 No

A radio?
[] 1 Yes
[] 2 No

A television?
[] 1 Yes
[] 2 No

A mobile telephone?
[] 1 Yes
[] 2 No

A washing machine?
[] 1 Yes
[] 2 No

A microwave oven?
[] 1 Yes
[] 2 No

An iron (for cloth)?
[] 1 Yes
[] 2 No

A table
[] 1 Yes
[] 2 No

A chair
[] 1 Yes
[] 2 No

A bed/cot
[] 1 Yes
[] 2 No

A mattress/blanket
[] 1 Yes
[] 2 No

A mat
[] 1 Yes
[] 2 No

A Kerosine lamp
[] 1 Yes
[] 2 No

An axe/bush knife/spade/hammer/hoe
[] 1 Yes
[] 2 No

A telephone
[] 1 Yes
[] 2 No

HC10. Does any member of your household own:

A watch?
[] 1 Yes
[] 2 No

A bicycle?
[] 1 Yes
[] 2 No

A motorcycle or scooter?
[] 1 Yes
[] 2 No

A car or truck?
[] 1 Yes
[] 2 No

A boat with a motor?
[] 1 Yes
[] 2 No

A canoe?
[] 1 Yes
[] 2 No

ITN module: TN

TN1. Does your household have any mosquito nets that can be used while sleeping?

[] 1 Yes
[] 2 No (Go to TN6B)

TN2. How many mosquito nets does your household have?
If 7 or more nets, record '7'.
Number of nets: _

TN3. Is the net (are any of the nets) any of the following brands:
Read each brand name, show picture card, and circle codes for Yes or No for each brand. If possible, observe the net to verify brand.
Long-lasting treated nets:
[] 1 Yes
[] 2 No (Go to TN6B)
[] 8 DK(Go to TN6B)
Other nets:
[] 1 Yes
[] 2 No(Go to TN6B)
[] 8 DK(Go to TN6B)

TN3C. How many long-lasting nets does your household have

Number of long lasting nets _

TN6. How many months ago was the (most recent) long lasting net obtained?
If less than 1 month ago, record '00'. If answer is "12 months" or "1 year", probe to determine if net was obtained exactly 12 months ago or earlier or later.
_ _ Months ago
[] 95 More than 24 months ago
[] 98 Not sure

TN6B. Do you know what causes malaria?

[] A Mosquito
[] B Mosquito and others
[] X Others (specify)
[] Z Don?t know

TN6C. Did you take any measure to prevent malaria?

[] 1 Yes
[] 2 No(Go to next module)

TN6D If yes, what measure have you taken to prevent malaria?

[] A Using mosquito nets
[] B Reduce mosquito breeding site
[] C Take medicine
[] D Sprayed home
[] X Others (specify)

TN6E. From where did you get this knowledge?

[] A Radio
[] B TV
[] C Printed materials
[] D Health workers
[] E Chief of church
[] F Relative/friend/neighbour
[] G School
[] X Other(specify)

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.

[] 1 Not iodized 0 PPM
[] 2 Less than 15 PPM
[] 3 15 PPM or more
[] 6 No salt in home
[] 7 Salt not tested

If it is a nutrition household, complete next section
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)

If it is a nutrition household, complete next section
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.)


Nutrition household: NH

NH1. Is it a nutrition household?

[] 1 Yes
[] 2 No (Go to next module)

NH2. If yes, label number for

Label Number:
Woman-1_____
Woman-2_____
Child -1_____
Child -2_____
Child -3_____