Good [fill in time of day]! My name is ____ and I am working for Central Statistics Office (CSO). We are working on a nationwide survey concerned with family health and education. We would very much appreciate your participation in this survey. The interview will take about 35 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. Locality name and cluster number:

HH2. Household number _ _ _

HH3. Interviewer name and number:

HH4. Supervisor name and number:

HH5. Day/month/year of interview _ _ / _ _ / 2009

HH6. Area:

HH7. Province: _ _

HH7A. District: _ _

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:

HH16A. Record interview time (hour and minute) _ _:_ _

HH16B. Data entry supervisor

HH16C. Field editor

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 is not enough room on this page.
[] 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

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

If age 18-59 years

HL8A. Has (name) been very sick for at least 3 months during the past 12 months?

For children age 0-17 years ask HL9-HL12AA

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

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

HL10A. If mother does not live in household:
Has (name's) mother been very sick for at least 3 months in the past 12 months?

HL10AA. If mother does not live in household:
Where does (name's) mother live?

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

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

HL12A. If father does not live in household:
Has (name's) father been very sick for at least 3 months in the past 12 months?

HL12AA. If father does not live in household:
Where does (name's) father live?

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.

Totals

Add a continuation sheet if there is not enough room on this page. Tick here if continuation sheet used [] listing. Then, ask questions starting with HL15 for each person at a time. Add a continuation sheet from another questionnaire if there is not enough room on this page. Tick here if continuation sheet from another questionnaire used []

For everybody in the household aged 15 and above, HL15-HL17

HL15. What is (name's) current marital status?

HL16. If married/ living with partners: Does partner/spouse live in household?

HL17. Where does partner/spouse live?

HL18. In the past 2 weeks, has (name) had any illness or injury? For example, has (name) had a cough, cold, diarrhoea, an accident or any other illness?

HL19. What symptoms did (name) suffer from during this time?
(See codes and enter a maximum of three symptoms)
HL20. Did (name) go to any health facility or receive any care from a doctor, nurse, traditional healer, or pharmacist?

HL21. Where did (name) go for advice or treatment?

Education Module: ED

Ask questions for household members age 3 years 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 3-24 years

ED4. During the (2009) 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?

ED6C. What type of school does (name) attend?

ED6D. Why did (name) not attend school?

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

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

Employment: EM

Ask questions for household members

EM1.

EM1A. Copy names from HL2

EM2.Is name under 5 years of age?

If (name) is 5 years and above ask EM3 and EM4

EM3. What was (name's) main activity in the last 12 months?

EM4. What other main activity did (name) engage in the last 12 months?

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.

WS4A. What is the availability of this source of water used for drinking?

WS4C. Is there water available today from this source?

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.

WS7A. Is toilet facility functional or not?
Request to see toilet facility and record whether functional or not
WS8. Do you share this facility with other households?

WS9. How many households in total use this toilet facility

WS10. How does your household dispose of refuse (solid waste)?

Household characteristics module: HC

HC1A. What is the religious affiliation of the head of this household?

HC1B. What is the main language used by the head of household?

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

HC3. Main material of the dwelling floor:
Record observation.
HC3A. Type of dwelling unit?
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.
HC8. Is the cooking usually done in the house, in a separate building, or outdoors?

HC9. Does your household have:












HC9A. Does your household have electric power now?

HC10. Does any member of your household own:








HC11. Does any member of this household own any land that can be used for agriculture?

HC12. How many hectares of agricultural land do members of this household own?
[This question is from optional modules]
If more than 97, record '97'. If unknown, record '98'.
HC13. Does this household own any livestock, herds, or farm animals?

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

Environmental Assessment: EN

Record your observation. Do not ask the respondent these questions

EN1.What is the general condition of the neighborhood with respect to garbage disposal?

EN2. What is the general condition of the area immediately around the house with respect to excreta removal?

EN3.What is the area around the respondent's house used for?

EN4. How would you describe the air quality in the neighborhood?
(Record all that apply)
Insecticide Treated Mosquito Nets: TN

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

TN2. How many mosquito nets does your household have?
If 7 or more nets, record '7'.
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:
TN3L1. Olyset?

Long-lasting treated nets:
TN3L2. Permanet

Pre-treated nets:
TN3p1. KO Tab 123

Pre-treated nets:
TN3P2. Iconet

TN3O4. Other (specify)_____

TN3O4. DK brand

TN3A. Where did you get the (name of net highest in the list of nets available in the household, in TN3) mosquito net?
Ask question in relation to the most effective mosquito net available in the household (Check TN3). If there is more than one net in the same category, ask question referring to the most recently obtained net.
TN4. Check TN3 for brand of net(s). Go through the above list in order until one box is checked and follow instructions

TN5. When you got the (most recent) net, was it already treated with an insecticide to kill or repel mosquitoes?

TN6. How many months ago was the (most recent) 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.
TN7. Since you got the net(s) has it (have any of these nets) ever been soaked or dipped in a liquid to kill/repel mosquitoes?

TN8. How long ago was the most recent soaking/dipping done?
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.
Children orphaned and made vulnerable by HIV/AIDS: OV

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 last 12 months?

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

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

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

2. Check totals for HL8A.

3. Check totals for HL10A and HL12A.

OV8. List all children aged 0-17 below. Record names, 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.

OV9. I would like to ask you about any formal, organized help or support that your household 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 household received for (name). In the last 12 months, has your household received any medical support for (name), such as medical care, supplies or medicine?

OV11. In the last 12 months, has your household 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 household receive any of this support in the past 3 months?

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

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

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

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

OV17. Check OV8 for age of child:

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

Poverty and household resources: PV

Read this to respondent and proceed with the questions that follow.
Now I would like to ask you about spending on health care and medicines in the last month.

PV1. In the past month, what was the total amount of money spent by your household on health care and medicines? Please include costs of visits to doctors, clinics, hospitals, traditional healers, transportation to and from those places and medicines you have bought.

PV2. In the past month, what was the total value of any help for health care and medicine received by this household from friends, relatives, employers, or organizations?

Now I would like to ask you about spending on education since the beginning of this year

PV3. Since the beginning of January, what was the total amount of money spent by your household on expenses related to the education of children in this household? Include expenses such as school fees, uniforms, books, and transportation.

PV4. Since the beginning of January, what was the total value of any education-related help received by this household? Please Include any scholarships, help with fees, uniforms, books, etc.

Now, I would like to ask you whether you or anyone else in this household received any financial or other help or support for which you did not have to pay

PV5. Did anyone in your household receive any such support during the last 6 months?

PV6. Who provided you with help? (circle all that apply)

PV7. What sort of help did you receive? (circle all that apply)