IDENTIFICATION (1)

PLACE NAME___________________________
NAME OF HOUSEHOLD HEAD__________________________
CLUSTER NUMBER __ __ __ __
HOUSEHOLD NUMBER __ __ __ __
HOUSEHOLD SELECTED FOR MAN'S SURVEY

INTERVIEWER VISITS

FIRST VISIT

SECOND VISIT

THIRD VISIT

NEXT VISIT:

FINAL VISIT

TOTAL NUMBER OF VISITS

*RESULT CODES:

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)_______________

LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF QUESTIONNAIRE ENGLISH

TRANSLATOR USED

**LANGUAGE CODES:
01 ENGLISH
02 LANGUAGE 2
03 LANGUAGE 3
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6

SUPERVISOR

FIELD EDITOR

OFFICE EDITOR

KEYED BY

NOTE: Questions with pink highlighting in the question number column are malaria-related questions that may be deleted in some circumstances (see footnotes). Brackets [] indicate items that should be adapted on a country-specific basis.

INTRODUCTION AND CONSENT (2)

Hello. My name is______________________. I am working with [NAME OF ORGANIZATION]. We are conducting a survey about health all over [NAME OF COUNTRY]. The information we collect will help the government to plan health services. Your household was selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15 to 20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don't have to be in the survey, but we hope you will agree to answer the questions since your views are important. If I ask you any question you don't want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

Do you have any questions?
May I begin the interview now?

100. RECORD THE TIME

HOUSEHOLD SCHEDULE

1. LINE NO.

2. USUAL RESIDENTS AND VISITORS

Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 FOR EACH PERSON.

3. RELATIONSHIP TO THE HEAD OF THE HOUSEHOLD

What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

SEX

4. Is (NAME) male or female?

RESIDENCE

5. Does (NAME) usually live here?

6. Did (NAME) stay here last night?

AGE

7. How old is (NAME)?
IF 95 OR MORE, RECORD '95'.

IF AGE 16 OR OLDER

8. MARITAL STATUS

What is (NAME)'s current marital status?

9. ELIGIBILITY

10. IF HOUSEHOLD SELECTED FOR MAN'S SURVEY

11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5.

IF AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

12. Is (NAME)'s natural mother alive?

13. Does (NAME)'s natural mother usually live in this household or was she a guest last night?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.

14. Is (NAME)'s natural father alive?

15. Does (NAME)'s natural father usually live in this household or was he a guest last night?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

IF AGE 6 YEARS OR OLDER
EVER ATTENDED SCHOOL

16. Has (NAME) ever attended school?

17. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

SEE CODES BELOW.

IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE

18.(3) Did (NAME) attend school at any time during the (2014-2015) school year?

19. During [this/that] school year, what level and grade [is/was] (NAME) attending?
SEE CODES BELOW.

IF AGE 0-4 YEARS
BIRTH REGISTRATION

20. Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

CODES FOR Qs. 17 and 19: Education

LEVEL
PRESCHOOL 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8

GRADE
LESS THAN 1 YEAR COMPLETED 0 (USE '00' FOR Q. 17 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 19)
DON'T KNOW 98

101. (4) What is the main source of drinking water for members of your household?

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

103. Where is that water source located?

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

105. CHECK 101 AND 102: CODE '14' OR '21' CIRCLED?

106. In the past two weeks, was the water from this source not available for at least one full day?

107. Do you do anything to the water to make it safer to drink?

108. What do you usually do to make the water safer to drink?
Anything else?

RECORD ALL MENTIONED.

109. (5) What kind of toilet facility do members of your household usually use?

IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

110. Do you share this toilet facility with other households?

111. Including your own household, how many households use this toilet facility?

112. Where is that facility located?

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

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

115. Do you have a separate room which is used as a kitchen?

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

117. Does this household own any livestock, herds, other farm animals, or poultry?

118. (6) How many or the following animals does this household own?
IF NONE, RECORD '00'. IF 95 OR MORE, RECORD '95'. IF UNKNOWN, RECORD '98'.

119. Does any member of this household own any agricultural land?

120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, RECORD '950'.

121. (7) Does your household have:

[ADD ADDITIONAL ITEMS. SEE FOOTNOTE 7.]

122. Does any member of this household own:

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

124. How often does anyone smoke inside your house?
Would you say daily, weekly, monthly, less often than once a month, or never?

125. (8) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

126. (8) Who sprayed the dwelling?

127. (9) Does your household have any mosquito nets?

128. (9) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

MOSQUITO NETS
QUESTIONS APPLY FOR NETS #1 THROUGH #3

129. (9) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

130. (9) How many months ago did you household get the mosquito nets?
IF LESS THAN ONE MONTHS AGO, RECORD '00'.

131. (9) OBSERVED OR ASK BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)

132. (9) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

133. (9) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.

134. (9) (10) Did you get the net through a [LOCAL NAME OF MASS DISTRIBUTION CAMPAIGN], during an antenatal care visit, or during an immunization visit?

135. (9) Where did you get the net?

136. (9) Did anyone sleep under this mosquito net last night?

137. (9) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.

138. (9) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139.

139. We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HAND WASHING.
RECORD OBSERVATION.

141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HAND WASHING.
RECORD OBSERVATION.

142. (5) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.

143. (5) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION

144. (5) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING

145. (11) I would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?

TEST SALT FOR IODINE.

146. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS:

TO BE FILLED IN AFTER COMPLETED INTERVIEW

COMMENTS ABOUT INTERVIEW:

COMMENTS ON SPECIFIC QUESTIONS:

A NY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS

EDITOR'S OBSERVATIONS

HOUSEHOLD: FOOTNOTES

(1) This section should be adapted for country-specific survey design.
(2) Increase the time reported to the respondent if modules are added to the questionnaire.
(3) In Q. 18, the year should refer to the school year that is in session at the time the survey begins. If the survey begins between two school years, then the year should refer to the school year that just ended.
(4) Countries that use sachet water (small plastic bags of water) as a source of drinking water should add SACHET WATER as a separate coding category after BOTTLED WATER, and follow the same question flow as households that use BOTTLED WATER (ask Q. 102, source coding category for other purposes). Similarly, countries that have water kiosks should add WATER KIOSK as a separate coding category, and follow the same question flow as households that use BOTTLED WATER.
(5) Coding categories to be developed locally; however, the broad categories must be maintained.
(6) Add other country-specific animals, such as oxen, water buffalo, camels, llamas, alpacas, pigs, ducks, geese, or elephants.
(7) Each country should add to the list at least five items of furniture (such as a table, chair, sofa, bed, armoire, cupboard, or cabinet). In addition, each country should add at least four additional household appliances so that the list includes at least three items that even a poor
household may have, at least three items that a middle income household may have, and at least three items that a high income household may have. Some possible additions are clock, water pump, grain grinder, fan, blender, water heater, generator, washing machine, microwave oven, DVD player, CD player, camera, air conditioner or cooler, sewing machine.
(8) The question should be deleted in countries that do not have a widespread organized spraying program to prevent the transmission of malaria.
(9) The question should be deleted in countries that are not affected by malaria.
(10) Adapt question locally to use the name of the mass distribution campaign.
(11) There are many different kinds of iodine testing kits available. The proper test kit should be selected in each country depending on the type of iodine additive used in the country (potassium iodate or potassium iodide). If both of these additives are used in a country, then both
types of test kits should be used.