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>[Version: 04 June 2018]
Samoa, 2019


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

HH7A. District name and code:

HH8. Is the household selected for questionnaire for men?

HH9. Is the household selected for water quality testing?

HH10. Is the household selected for blank testing?

Check that the respondent is a knowledgeable member of the household and at least 18 years old before proceeding. You may only interview a child age 15-17 if there is no adult member of the household or all adult members are incapacitated. You may not interview a child under age 15.

HH11. Record the time.

HH12. Hello, my name is (your name). We are from Samoa Bureau of Statistics. We are conducting a survey to better understand the health, well-being, and overall situation of children, families and households. I would like to talk to you about these subjects. This interview usually takes about 35 minutes. Following this, I may ask to conduct additional interviews with you or other individual members of your household. All the information we obtain will remain strictly confidential and anonymous. If you do not wish to answer a question or stop the interview, please let me know. May I start now?

HH46. Result of household questionnaire interview:
Discuss any result not completed with supervisor.
HH47. Name and line number of the respondent to household questionnaire interview:

To be filled after the Household Questionnaire is completed
Total number

HH48. Household members: __ __


HH49. Women age 15-49: __ __

HH50. If household is selected for questionnaire for men:
Men age 15-49: __ __

HH51. Children under age 5: __ __

HH52. Children age 5-17: __ __

To be filled after all the questionnaires are completed
Completed number

HH53. Women age 15-49: __ __

HH54. If household is selected for questionnaire for men (men age 15-49): __ __

HH55. Children under age 5: __ __

HH56. Children age 5-17

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List Of Household Members: HL

First complete HL2-HL4 vertically for all household members, starting with the head of the household. Once HL2-HL4 are complete for all members, make sure to probe for additional members: Those that are not currently at home, any infants or small children and any others who may not be family (such as servants, friends) but who usually live in the household.
Then, ask questions HL5-HL20 for each member one at a time. If additional questionnaires are used, indicate by ticking this box: ____

HL1. Line number: _ _

HL2. First, please tell me the name of each person who usually lives here, starting with the head of the household.
Probe for additional household members.
HL3. What is the relationship of (name) to (name of the head of household)?

HL4. Is (name) male or female?

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

HL6. How old is (name)?
Record in completed years.If age is 95 or above, record "95".
HL8. Record line number if woman and age 15-49: _ _

HL9. Record line number if man, age 15-49 and HH8 is yes: _ _

HL10. Record line number if age 0-4: _ _

HL11. Age 0-17?

HL12. Is (name)"s natural mother alive?

HL13. Does (name)'s natural mother live in this household?

HL14. Record the line number of mother and go to HL16: _ _

HL15. Where does (name)'s natural mother live?

HL16. Is (name)'s natural father alive?

HL17. Does (name)'s natural father live in this household?

HL18. Record the line number of father and go to HL20: _ _

HL19. Where does (name)'s natural father live?

HL20. Copy the line number of mother from HL14. If blank, ask: Who is the primary caretaker of (name)?
If "No one" for a child age 15-17, record "90".
Code for HL3. Relationship to head of household

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Education 1: ED

ED1. Line number: _ _

ED2. Name and age
Copy names and ages of all members of the household from HL2 and HL6 to below and to next page of the module.
ED3. Age 3 or above?

ED4. Has (name) ever attended school or any early childhood education programme?

ED5. What is the highest level and grade or year of school (name) has ever attended?

ED6. Did (name) ever complete that year?

ED7. Age 3-24?

ED8. Check ED4: Ever attended school or ECE?
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Education 2: ED

ED1. Line number _ _

ED2. Name and age

ED9. At any time during the 2019 school year did (name) attend school or any early childhood education programme?

ED10. During the 2019 school year, which level and grade or year is (name) attending?

ED11. Is (he/she) attending a public school?
If "Yes", record "1". If "No", probe to code who controls and manages the school.
ED12. In the 2019 school year, has (name) received any school tuition support?

ED13. Who provided the tuition support?
Record all mentioned.
ED14. For the 2019 school year, has (name) received any material support or cash to buy shoes, exercise books, notebooks, school uniforms or other school supplies?
If "Yes", probe to ensure that support was not received from family, other relatives, friends or neighbours.
ED15. At any time during the 2018 school year did (name) attend school or any early childhood education programme?

ED16. During that 2018 school year, which level and grade or year did (name) attend?

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Chronic Diseases: CD

Read the introductory statement first before asking each question:
Now I would like to ask you about some diseases that you or any other members of your household may have had in the last 12 months

CD1. Line number: _ _

CD2. Name and age:
Copy names and ages of all members of the household from HL2 and HL6 to below
CD3. Age 25 or above?
CD4. In the last 12 months, has (name) been diagnosed with diabetes by a medical doctor?

CD5. In the last 12 months, has (name) been diagnosed with hypertension by a medical doctor?

CD6. In the last 12 months, has (name) been diagnosed with cardiovascular disease by a medical doctor?

CD7. In the last 12 months, has (name) been diagnosed with rheumatic heart disease by a medical doctor?

CD8. In the last 12 months, has (name) been diagnosed with cancer by a medical doctor?

Household Characteristics: HC

HC1A. What is the religion of (name of the head of the household from HL2)?

HC1B. What is the mother tongue/native language of (name of the head of the household from HL2)?

HC2. To what ethnic group does (name of the head of the household from HL2) belong?

HC2A. Type of house of the main house
Record observation. If observation is not possible, ask the respondent to determine the ty[e of house of the main house.
HC3. How many rooms do members of this household usually use for sleeping?

HC4. Main material of the dwelling floor.
Record observation. If observation is not possible, ask the respondent to determine the material of the dwelling floor.
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HC5. Main material of the roof.
Record observation.

HC6. Main material of the exterior walls.
Record observation.
HC7. Does your household have:

A. A fixed telephone line?

B. A radio?

C. A table?

D. A bed?

E. A sofa?

F. A chair?

G. A food safe?

H. A cupboard?

HC8. Does your household have electricity?

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HC9. Does your household have:

A. A television?

B. A refrigerator?

C. A washing machine?

D. An electric kettle?

E. An electric iron?

F. An electric fan?

G. A freezer?

HC10. Does any member of your household own:

A. A wristwatch?

B. A bicycle?

C. A motorcycle or scooter?

D. An animal-drawn cart?

E. A car, truck or van?

F. A boat with a motor?

G. A canoe?

H. A fishing line?

I. A fishing net?

J. A fishing spear?

HC11. Does any member of your household have a computer or a tablet?

HC12. Does any member of your household have a mobile telephone?

HC13. Does your household have access to internet at home?

HC14. 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", record "2". For other responses, record "6" and specify.
HC15. Does any member of this household own any land that can be used for agriculture?

HC16. How many acres of agricultural land do members of this household own?
If ¼ acres, record 00.25, if ½ acres, record 00.50.
HC17. Does this household own any livestock, herds, other farm animals, or poultry?

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HC18. 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. Milk cows or bulls?

B. Other cattle?

C. Horses, donkeys or mules?

D. Goats?

E. Sheep?

F. Chickens?

G. Pigs?

H. Ducks?

HC19. Does any member of this household have a bank account?

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Social Transfers: ST

ST1. I would like to ask you about various external economic assistance programmes provided to households. By external assistance I mean support that comes from the government or from non-governmental organizations such as religious, charitable, or community-based organizations. This excludes support from family, other relatives, friends or neighbours.

ST2. Are you aware of (name of programme)?

ST3. Has your household or anyone in your household received assistance through (name of programme)?

ST4. When was the last time your household or anyone in your household received assistance through (name of programme)?
If less than one month, record "1" and record "00" in Months. If less than 12 months, record "1" and record in Months. If 1 year/12 months or more, record "2" and record in Years.
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Household Energy Use: EU

EU1. In your household, what type of cookstove is mainly used for cooking?

EU4. What type of fuel or energy source is used in this cookstove?
If more than one, record the main energy source for this cookstove.
EU5. Is the cooking usually done in the house, in a separate building, or outdoors?
If in main house, probe to determine if cooking is done in a separate room. If outdoors, probe to determine if cooking is done on veranda, covered porch, or open air.
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EU9. At night, what does your household mainly use to light the household?

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Water and sanitation: WS

WS1. What is the main source of drinking water used by members of your household?
If unclear, probe to identify the place from which members of this household most often collect drinking water (collection point).
WS1A. Who is the main supplier of the drinking water?

WS1B. Is the pipe metered or not metered?

WS1C. Check WS1 Piped water as a main source of drinking water
WS2. What is the main source of water used by members of your household for other purposes such as cooking and handwashing?
If unclear, probe to identify the place from which members of this household most often collect water for other purposes.
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WS3. Where is that water source located?

WS4. How long does it take for members of your household to go there, get water, and come back?

WS5. Who usually goes to this source to collect the water for your household?
Record the name of the person and copy the line number of this person from the list of household members module.

WS6. Since last (day of the week), how many times has this person collected water?

WS7. In the last month, has there been any time when your household did not have sufficient quantities of drinking water?

WS8. What was the main reason that you were unable to access water in sufficient quantities when needed?

WS9. Do you or any other member of this household do anything to the water to make it safer to drink?

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WS10. What do you usually do to make the water safer to drink?
Probe: Anything else?
Record all methods mentioned.
WS11. What kind of toilet facility do members of your household usually use?
If "Flush" or "Pour flush", probe: Where does it flush to?
If not possible to determine, ask permission to observe the facility.
WS12. Has your (answer from WS11) ever been emptied?

WS13. The last time it was emptied, where were the contents emptied to?
Probe: Was it removed by a service provider?
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WS14. Where is this toilet facility located?

WS15. Do you share this facility with others who are not members of your household?

WS16. Do you share this facility only with members of other households that you know, or is the facility open to the use of the general public?

WS17. How many households in total use this toilet facility, including your own household?

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Handwashing: HW

HW1. We would like to learn about where members of this household wash their hands. Can you please show me where members of your household most often wash their hands?
Record result and observation.
HW2. Observe presence of water at the place for handwashing.
Verify by checking the tap/pump, or basin, bucket, water container or similar objects for presence of water.
HW3. Is soap or detergent or ash/mud/sand present at the place for handwashing?

HW4. Where do you or other members of your household most often wash your hands?

HW5. Do you have any soap or detergent in your house for washing hands?

HW6. Can you please show it to me?

HW7. Record your observation.
Record all that apply.
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Salt Iodisation: SA

SA1. We would like to check whether the salt used in your household is iodised. May I have a sample of the salt used to cook meals in your household?
Apply 2 drops of test solution, observe the darkest reaction within 30 seconds, compare to the colour chart and then record the response (1, 2 or 3) that corresponds to test outcome.
SA2. I would like to perform one more test. May I have another sample of the same salt?
Apply 5 drops of recheck solution. Then apply 2 drops of test solution on the same spot. Observe the darkest reaction within 30 seconds, compare to the colour chart and then record the response (1, 2 or 3) that corresponds to test outcome.
HH13. Record the time.

HH14. Language of the Questionnaire.

HH15. Language of the Interview.

HH16. Native language of the Respondent.

HH17. Was a translator used for any parts of this questionnaire?

HH17A. Household phone number

HH18. Check HL6 in the "List of household members" and indicate the total number of children age 5-17 years:
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HH19. List each of the children age 5-17 years below in the order they appear in the list of household members. Do not include other household members outside of the age range 5-17 years. Record the line number, name, sex, and age for each child.

HH20. Rank number: _

HH21. Line number from HL1: _ _

HH22. Name from HL2: ____

HH23. Sex from HL4

HH24. Age from HL6: _ _

HH25. Check the last digit of the household number (HH2) from the household information panel. This is the number of the row you should go to in the table below.
Check the total number of children age 5-17 years in HH18 above. This is the number of the column you should go to in the table below.
Find the box where the row and the column meet and record the number that appears in the box. This is the rank number (HH20) of the selected child.

HH26. Record the rank number (HH20), line number (HH21), name (HH22) and age (HH24) of the selected child.

HH27. (When HH18=1 or when there is a single child age 5-17 in the household): Record the rank number as "1"and record the line number (HL1), the name (HL2) and age (HL6) of this child from the list of household members.

HH28. Issue a questionnaire for children age 5-17 to be administered to the mother/caretaker of this child.

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HH29. Check HL8 in the list of household members: Are there any women age 15-49?
HH30. Issue a separate questionnaire for individual women for each woman age 15-49 years.

HH31. Check HL6 and HL8 in the list of household members: Are there any girls age 15-17?
HH32. Check HL20 in the list of household members: Is consent required for interviewing at least one girl age 15-17?
HH33. As part of the survey we are also interviewing women age 15-49. We ask each person we interview for permission. A female interviewer conducts these interviews.
For girls age 15-17 we must also get permission from an adult to interview them. As mentioned before, all the information we obtain will remain strictly confidential and anonymous.
May we interview (name(s) of female member(s) age 15-17) later?

HH34. Check HH8 in the household information panel: Is the household selected for Questionnaire for Men?
HH35. Check HL9 in the "List of household members": Are there any men age 15-49?

HH36. Issue a separate questionnaire for individual men for each man age 15-49 years.

HH37. Check HL6 and HL8 in the list of household members: Are there any boys age 15-17?

HH38. Check HL20 in the "List of household members": Is consent required for interviewing at least one boy age 15-17?

HH39. As part of the survey we are also interviewing men age 15-49. We ask each person we interview for permission. A male interviewer conducts these interviews.
For boys age 15-17 we must also get permission from an adult to interview them. As mentioned before, all the information we obtain will remain strictly confidential and anonymous.
May we interview (name(s) of male member(s) age 15-17) later?

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HH40. Check HL10 in the "List of household members": Are there any children age 0-4?
HH41. Issue a separate questionnaire for children under five for each child age 0-4 years.

HH42. Check HH9 in the household information panel: Is the household selected for water quality testing questionnaire?
HH43. Issue a separate water quality testing questionnaire for this household

HH44. As part of the survey we are also looking at the quality of drinking water. We would like to do a simple test of your drinking water. A colleague will come and collect the water samples. May we do such a test?
If the respondent requests to learn the results, explain that results will not be shared with individual households but will be made available to local authorities.
HH45. Now return to the household information panel and,
Record "01" in question HH46 (Result of the Household Questionnaire interview). Record the name and the line number (from the list of household members) of the respondent to the household questionnaire interview in HH47. Fill the questions HH48 ? HH52. Thank the respondent for his/her cooperation and then proceed with the administration of the remaining individual questionnaire(s) in this household.
If there is no individual questionnaire and no water quality testing questionnaire to be completed in this household thank the respondent for his/her cooperation and move to the next household you have been assigned by your supervisor.

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Interviewer's Observations ________

Supervisor's Observations ________