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REPUBLIC OF ANGOLA
MULTIPLE INDICATORS AND HEALTH SURVEYS

HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

STATISTICAL CONFIDENTIALITY: BY THE TERMS GIVEN IN ARTICLE 11 OF THE LAW NO. 3/11, FROM THE 14TH OF JANUARY, LAW OF THE NATIONAL STATISTICS SYSTEM, ALL INDIVIDUAL DATA COLLECTED BY OFFICIAL STATISTICS ORGANIZATIONS, IN THIS CASE THE INE, ARE STRICTLY CONFIDENTIAL. COLLECTED DATA IS PROTECTED FROM ANY NON-STATISTICAL PURPOSES OR FROM ANY UNAUTHORIZED DISSEMINATION, ONLY TO BE USED FOR THE PRODUCTION OF OFFICIAL STATISTICS.

PLACE NAME/ADDRESS________
NAME OF HOUSEHOLD HEAD________
PROVINCE ____
MUNICIPALITY ____
COMMUNE ____
NEIGHBORHOOD/VILLAGE ____
CENSUS SECTION ____
HOUSEHOLD AREA ____

URBAN 1
RURAL 2

CLUSTER NUMBER (ID. IIMS) ____
HOUSEHOLD NUMBER ____
HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1
NO 2

HOUSEHOLD SELECTED FOR CHILDREN'S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT
DATE_________
INTERVIEWER'S NAME_________
RESULT*

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

NEXT VISIT:
DATE_________
TIME_________

SECOND VISIT
DATE_________
INTERVIEWER'S NAME_________
RESULT*

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

NEXT VISIT:
DATE_________
TIME_________

THIRD VISIT
DATE_________
INTERVIEWER'S NAME_________
RESULT*

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

FINAL VISIT
DAY____
MONTH___
YEAR____
INTERVIEWER NUMBER_____
RESULT*

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

TOTAL NUMBER OF VISITS_________

TOTAL PERSONS IN HOUSEHOLD_________
TOTAL NO. OF WOMEN AGES 15-49_________
TOTAL NO. OF MEN AGES 15-54_________
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_________

LANGUAGE OF QUESTIONNAIRE:

PORTUGUESE 1
CHOKWE/KIOKO 2
FIOTE 3
KIKONGO/UKONGO 4
KIMBUNDU 5
KWANHAMA 6
LUVALE 7
MUHUMBI 8
NGANGUELA 9
NHANECA 10
UMBUNDU 11
OTHER (SPECIFY)_________ 96

TRANSLATOR USED:

YES 1
NO 2

SUPERVISOR
NAME_____
NUMBER_____

INTRODUCTION AND CONSENT

Good morning/good afternoon. My name is ________. I am an interviewer with the National Institute of Statistics and this is my identification card(SHOW YOUR ID CARD). We are conducting a national survey about a variety of health topics. The information we collect will help the government to plan and improve health services.
Your household was selected for the survey. All the answers you give will be confidential and will not be shared with anyone other than members of the survey team.
Your participation in the survey is voluntarily and if there is a question you don't want to answer, just let me know and I will go to the next question or you can stop the interview at any time. In case that you need more information about the survey, you may contact INE or any INE's Province Services.

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

SIGNATURE OF INTERVIEWER__________ DATE_______

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 100)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

100) RECORD THE TIME WHEN YOU BEGIN THE INTERVIEW

HOURS ____
MINUTES ____

SECTION 1: LIST AND BASIC CHARACTERISTICS OF MEMBERS OF HOUSEHOLD

1) LINE NUMBER____

2) USUAL RESIDENTS AND VISITORS
Please give 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 FILLING OUT THE NAMES, RELATIONS AND SEX OF EACH PERSON, ASK QUESTIONS 2A-2C, TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK QUESTIONS FROM COLUMNS 5-20 TO EACH PERSON.

NAME____

3) RELATIONSHIP TO HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household? SEE CODES BELOW.

HEAD 1
SPOUSE 2
SON OR DAUGHTER 3
SON IN LAW OR DAUGHTER IN LAW 4
GRANDCHILD 5
PARENT 6
MOTHER/FATHER IN LAW 7
BROTHER OR SISTER 8
OTHER RELATIVE 9
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98

4) SEX
Is (NAME) male or female?

MALE 1
FEMALE 2

5) RESIDENCE
Does (NAME) usually live here?

YES 1
NO 2

6) RESIDENCE
Did (NAME) stay here last night?

YES 1
NO 2

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

AGE IN YEARS ____

8) FOR PEOPLE AGE 15 OR OLDER
MARITAL STATUS What is (NAME)'s current marital status?

MARRIED OR LIVING TOGETHER 1
DIVORCED 2
SEPARATED 3
WIDOWED 4
SINGLE / NEVER LIVED TOGETHER 5

9) ELIGIBILITY
CIRCLE THE LINE NUMBER OF ALL WOMEN AGE 15-49

LINE NUMBER____

10) ELIGIBILITY
IF HOUSEHOLD SELECTED FOR MAN'S SURVEY
CIRCLE THE LINE NUMBER OF ALL MEN AGE 15-54

LINE NUMBER____

11) ELIGIBILITY
CIRCLE THE LINE NUMBER OF ALL CHILDREN AGE 0-5

LINE NUMBER____

11A) ELIGIBILITY
CIRCLE THE LINE NUMBER OF ALL CHILDREN AGE 5-17

LINE NUMBER____

2A) Just to make sure that the listing is complete: are there any other people such as small infants or babies that were not listed?

YES __ (INCLUDE ON THE LIST)
NO __

2B) Are there any other people who are not family members such as domestic servants, lodgers, or friends who usually live here?

YES __ (INCLUDE ON THE LIST)
NO __

2C) Are there any guests or temporary visitors staying here

YES __ (INCLUDE ON THE LIST)
NO __

SECTION 2: ORPHANAGE

FOR PEOPLE AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

12) Is (name's) biological mother alive?

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)

13) Does (NAME'S) biological mother live in this house?
IF YES: What is her name?
RECORD THE MOTHER'S LINE NUMBER.
IF NO: RECORD '00'.

LINE NUMBER____

14) Is (NAME'S) biological father alive?

YES 1
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)

15) Does (NAME'S) biological father live in this household?
IF YES: What is his name?
RECORD THE FATHER'S LINE NUMBER.
IF NO: RECORD '00'.

LINE NUMBER____

SECTION 3: EDUCATION

FOR PEOPLE 3 YEARS OR OLDER
FREQUENCY OF ATTENDANCE IN SCHOOL

16) Has (NAME) ever attended school or daycare?

YES 1
NO 2 (GO TO 24)

16A) What is the highest year or grade in school that (NAME) has attended?

CLASS/YEAR ________

17) Did (NAME) successfully complete this year?

YES 1
NO 2

17A) What level of schooling corresponds with year/grade?
SEE CODES BELOW.

LEVEL
BASIC LITERACY 0
PRE-PRIMARY SCHOOL 1
PRIMARY 2
SECONDARY 1ST CYCLE 3
SECONDARY 2ND CYCLE 4
BACHELOR 5
LICENTIATE/PROFESSIONAL 6
MASTER 7
DOCTORATE 8
DOES NOT KNOW 9
YEAR/GRADE
INITIATION 90
BASIC LITERACY 91
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE 12
13TH GRADE 13
1ST YEAR 14
2ND YEAR 15
3RD YEAR 16
4TH YEAR 17
5TH YEAR 18
6TH YEAR19
DOES NOT KNOW 20

FOR PEOPLE 3-24 YEARS OLD
CURRENT SCHOOL ATTENDANCE

18) For the current school year, is (NAME) enrolled in school or daycare?

YES 1
NO 2

19) At any time during the 2015/16 school year, has (NAME) attended school?

YES 1
NO 2 (GO TO 22)

20) For the current school year, what grade (year) did (NAME) attend?

LEVEL
BASIC LITERACY 0
PRE-PRIMARY SCHOOL 1
PRIMARY 2
SECONDARY 1ST CYCLE 3
SECONDARY 2ND CYCLE 4
BACHELOR 5
LICENTIATE/PROFESSIONAL 6
MASTER 7
DOCTORATE 8
DOES NOT KNOW 9
YEAR/GRADE
INITIATION 90
BASIC LITERACY 91
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE 12
13TH GRADE 13
1ST YEAR 14
2ND YEAR 15
3RD YEAR 16
4TH YEAR 17
5TH YEAR 18
6TH YEAR19
DOES NOT KNOW 20

FOR PEOPLE 5-12 YEARS OLD
SCHOOL LUNCH
21) For the current school year, does (did) (NAME) receive free school lunch?

YES 1
NO 2

FOR PEOPLE 3-24 YEARS OLD
LAST YEAR'S SCHOOL ATTENDANCE
22) Did (NAME) attend school or daycare during last school year?

YES 1
NO 2 (GO TO 24)

23) What grade (year) did (s)he attend during the last school year?

LEVEL
BASIC LITERACY 0
PRE-PRIMARY SCHOOL 1
PRIMARY 2
SECONDARY 1ST CYCLE 3
SECONDARY 2ND CYCLE 4
BACHELOR 5
LICENTIATE/PROFESSIONAL 6
MASTER 7
DOCTORATE 8
DOES NOT KNOW 9
YEAR/GRADE
INITIATION 90
BASIC LITERACY 91
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE 12
13TH GRADE 13
1ST YEAR 14
2ND YEAR 15
3RD YEAR 16
4TH YEAR 17
5TH YEAR 18
6TH YEAR19
DOES NOT KNOW 20

23A) What level of schooling corresponds to this grade (year)?

LEVEL
BASIC LITERACY 0
PRE-PRIMARY SCHOOL 1
PRIMARY 2
SECONDARY 1ST CYCLE 3
SECONDARY 2ND CYCLE 4
BACHELOR 5
LICENTIATE/PROFESSIONAL 6
MASTER 7
DOCTORATE 8
DOES NOT KNOW 9
YEAR/GRADE
INITIATION 90
BASIC LITERACY 91
1ST GRADE 1
2ND GRADE 2
3RD GRADE 3
4TH GRADE 4
5TH GRADE 5
6TH GRADE 6
7TH GRADE 7
8TH GRADE 8
9TH GRADE 9
10TH GRADE 10
11TH GRADE 11
12TH GRADE 12
13TH GRADE 13
1ST YEAR 14
2ND YEAR 15
3RD YEAR 16
4TH YEAR 17
5TH YEAR 18
6TH YEAR19
DOES NOT KNOW 20

SECTION 4: DISABILITY

FOR PEOPLE 0 TO 17 YEARS OLD
24) PHYSICAL OR MENTAL DISABILITY: Does (NAME) have any type of physical or mental disability?

YES 1
NO 2 (GO TO 26)

25) PHYSICAL OR MENTAL DISABILITY: What type of disability does (NAME) have?

BLIND 1
DEAF 2
DEAF/MUTE 3
DIMINISHED MENTAL FUNCTIONING 4
PARALYZED 5
AMPUTATED LOWER LIMBS 6
AMPUTATED UPPER LIMBS 7
OTHER (SPECIFY) ____ 8

SECTION 5: BIRTH REGISTRATION

FOR PEOPLE 0-17 YEARS OLD
26) BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF YES, ASK:
Please, may I see the certificate?

YES, CERTIFICATE SEEN 1
YES, BUT CERTIFICATE NOT SEEN 2
NOT REGISTERED 3
DOES NOT KNOW 4

26A) Do you know what you need to do to register a child with the General Registry?

YES 1
NO 2 (GO TO 27)

26B) What documents are required to register a child?
MULTIPLE CHOICE

VALID B1 FROM PARENTS/GODPARENTS A
MATERNITY DOCUMENT B
THE BABY'S VACCINE CARD C
RECEIPT OF SERVICE PAYMENT D
GO TO THE GENERAL REGISTRY E
OTHER (SPECIFY) ____ X
DOES NOT KNOW Z

TABLE FOR SELECTION OF WOMEN FOR DOMESTIC VIOLENCE SECTION

27) REVIEW 9: NUMBER OF WOMEN BETWEEN 15-49 YEARS OLD

ZERO (GO TO 31)
ONE (GO TO 28 AND RECORD THE WOMAN'S NAME AND LINE NUMBER)
TWO OR MORE (LOOK AT THE LAST DIGIT OF THE SERIAL NUMBER ON THE COVER OF THIS SURVEY. THIS DIGIT CORRESPONDS TO THE LINE NUMBER. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9). THIS NUMBER CORRESPONDS TO THE NUMBER IN THE COLUMN. CIRCLE THE NUMBER IN THE INTERSECTION OF THE LINE AND THE COLUMN. THIS NUMBER INDICATES THE POSITION OF THE WOMAN (COLUMN 9), WHO WAS SELECTED FOR THE DOMESTIC VIOLENCE MODULE. RECORD THE NAME AND SERIAL NUMBER OF SELECTED WOMAN BELOW.)

EXAMPLE: THE SERIAL NUMBER OF THE QUESTIONNAIRE IS '716' AND COLUMN 9 OF THE HOUSEHOLD QUESTIONNAIRE INDICATES THAT THE HOUSEHOLD HAS THREE ELIGIBLE WOMEN OF AGE 15-49. THE LAST DIGIT OF THE SERIAL NUMBER IS '6' WHICH CORRESPONDS TO LINE '6'. IN THE SAME MANNER, THE HOUSEHOLD HAS THREE ELIGIBLE WOMEN THAT CORRESPOND TO LINE '3'. THE INTERSECTION OF LINE '6' AND LINE '3' IS THE NUMBER '2'. CIRCLE THIS NUMBER. GO BACK TO THE LIST OF THE HOUSEHOLD QUESTIONNAIRE AND SEARCH FOR THE SECOND WOMAN ELIGIBLE FOR THE DOMESTIC VIOLENCE MODULE. (IN THIS CASE THE WOMAN WITH LINE NUMBER '04'). RECORD THE NAME AND THE NUMBER OF ORDER BELOW.

[LINE 1] LAST DIGIT OF HOUSEHOLD'S NUMBER 0123456789

[NEXT EIGHT LINES] TOTAL NUMBER OF ELIGIBLE WOMEN OF AGE 15-49 IN THE HOUSEHOLD (COLUMN 9) [NUMBERED CHART]

28) NAME OF SELECTED WOMEN________
LINE NUMBER OF SELECTED WOMEN ___

SELECTION OF CHILD FOR CHILD LABOR SECTION

31) CHECK COLUMN 11A THE HOUSEHOLD LISTING AND RECORD THE TOTAL NUMBER OF CHILDREN AGES 5-17

TOTAL NUMBER ____

32) CHECK 31: NUMBER OF CHILDREN AGES 5-17

ZERO (GO TO 60)
ONE (GO TO 40 AND RECORD THE POSITION '1', LINE NUMBER, AND THE NAME AND AGE OF THE CHILD)
TWO OR MORE

32A) INCLUDE EACH CHILD AGES 5-17 IN THE ORDER OF APPEARANCE IN THE HOUSEHOLD LIST. DO NOT INCLUDE MEMBERS OF THE HOUSEHOLD OUTSIDE OF THE AGES 5-17. RECORD THE LINE NUMBER, NAME, SEX AND AGE OF EACH CHILD.

33) POSITION NUMBER

NUMBER____

34) LINE NUMBER

NUMBER ____

35) NAME IN COLUMN 2

NAME____

36) SEX IN COLUMN 4

MALE 1
FEMALE 2

37) AGE IN COLUMN 7

AGE ____

TABLE FOR SELECTION OF CHILD FOR CHILD LABOR SECTION

38) SEE THE LAST DIGIT OF LINE NUMBER OF THIS QUESTIONNAIRE, THIS DIGIT CORRESPONDS TO THE LINE NUMBER. CHECK TOTAL NUMBER OF ELIGIBLE CHILDREN IN QUESTION 31. THIS NUMBER CORRESPONDS TO THE NUMBER OF THE COLUMN. CIRCLE THE NUMBER THAT APPEARS AT THE INTERSECTION OF THE LINE AND THE COLUMN. THIS NUMBER INDICATES THE POSITION OF THE CHILD (QUESTION 31) SELECTED FOR CHILD LABOR SECTION. RECORD THE NAME, LINE NUMBER AND THE POSITION OF THE SELECTED CHILD OF QUESTION 39.

EXAMPLE: THE LINE NUMBER OF THE QUESTIONNAIRE IS '716' AND QUESTION 31 INDICATES THAT THE HOUSEHOLD HAS THREE ELIGIBLE CHILDREN AGES 5-17. THE LAST DIGIT OF THE SERIAL NUMBER IS '6', WHICH CORRESPONDS TO LINE '6'. IN THE SAME MANNER, THE HOUSEHOLD HAS THREE ELIGIBLE CHILDREN THAT CORRESPOND TO COLUMN '3'. THE INTERSECTION OF LINE '6' AND COLUMN '3' IS NUMBER '2'. CIRCLE THE NUMBER. GO BACK TO QUESTION 33 AND LOOK UP THE SECOND CHILD. RECORD THE NAME, LINE NUMBER AND POSITION OF THE CHILD IN THE QUESTION BELOW 39.

[LINE 1] LAST DIGIT OF HOUSEHOLD'S NUMBER 0123456789

[NEXT EIGHT LINES] TOTAL NUMBER OF ELIGIBLE CHILDREN AGES 5-17 IN THE HOUSEHOLD (QUESTION 31) [NUMBERED CHART]

39) NAME OF SELECTED CHILD________
LINE NUMBER OF SELECTED CHILD___
POSITION OF SELECTED CHILD____

SECTION 6: CHILD LABOR

40) RECORD THE LINE NUMBER AND THE AGE OF THE SELECTED CHILD

NAME_______
LINE NUMBER ___
AGE___

41) Now I would like to ask a few questions about the work some children in this household may do.

In the last 7 days (NAME OF CHILD):

Worked at least 1 hour in any remunerated activity in money or kind, including domestic labor?
Conducted any type of business by him/herself, or with other people?
Helped in a family business without receiving any type of payment?
Worked in any type of labor for the household's consumption without any remuneration?

WORKED IN A REMUNERATED ACTIVITY
YES 1
NO 2
WORKED BY HIM/HERSELF
YES 1
NO 2
HELPED IN THE FAMILY BUSINESS WITHOUT REMUNERATION
YES 1
NO 2
WORKED IN ANY TYPE OF LABOR FOR THE HOUSEHOLD'S CONSUMPTION WITHOUT REMUNERATION
YES 1
NO 2

42) CHECK 41A AND 41B

AT LEAST ONE 'YES'
ALL ANSWERS ARE 'NO' (GO TO 47)

43) In the last 7 days, how many hours (NAME OF THE CHILD) worked in this (these) activity(ies) ?
IF LESS THAN ONE HOUR, RECORD '00'

NUMBER OF HOURS _____

44) Did (NAME OF CHILD) have to carry heaving things in those activities?

YES 1
NO 2
DON'T KNOW 8

45) (In this activity/these activities) (NAME OF CHILD) used dangerous tools such as axe, knives or machetes, or did s/he operated heavy machinery in order to do the work?

YES 1
NO 2
DON'T KNOW 8

46) How is the environment in which (NAME OF CHILD) works:

Is (NAME OF CHILD) exposed to dust, smoke or gas?
YES 1
NO 2
DON'T KNOW 8
Is (NAME OF CHILD) exposed to extreme cold, heat or humidity?
YES 1
NO 2
DON'T KNOW 8
Is (NAME OF CHILD) exposed to noise, sound or vibration?
YES 1
NO 2
DON'T KNOW 8
Does (NAME OF CHILD) work in high places, such as a ladder or scaffold?
YES 1
NO 2
DON'T KNOW 8
Does (NAME OF CHILD) work with chemical products (pesticides, adhesives, etc.) or explosives?
YES 1
NO 2
DON'T KNOW 8

47) In the last 7 days, has (NAME OF CHILD) helped transporting water or collect firewood for household use?

YES 1
NO 2 (GO TO 49)

48) In the last 7 days, how many hours did (NAME OF CHILD) helped transporting water or collecting firewood for household use?
IF LESS THAN ONE HOUR, RECORD '00'

NUMBER OF HOURS___

49) In the last 7 days did (NAME OF CHILD) help with any of the following household chores in this household?

Go shopping for the household?
Fix a household device?
Cook, wash dishes or clean the house?
Wash clothes?
Take care of other children?
Take care of elder or sick members of the household?
Other domestic chores?

GO SHOPPING
YES 1
NO 2
FIX A DEVICE
YES 1
NO 2
COOK/CLEAN UP
YES 1
NO 2
WASH CLOTHES
YES 1
NO 2
TAKE CARE OF CHILDREN
YES 1
NO 2
TAKE CARE OF ELDER OR SICK PEOPLE
YES 1
NO 2
OTHER DOMESTIC CHORES
YES 1
NO 2

50) CHECK 49A THROUGH 49G:

AT LEAST ONE 'YES'
ALL ANSWERS ARE 'NO' (GO TO 52)

51) In the last 7 days, how many hours did (NAME OF CHILD) work in this (those) activity (activities) ?
IF LESS THAN ONE HOUR, RECORD '00'

NUMBER OF HOURS___

52) CHECK 40:

THE SELECTED CHILD IS 5-17 YEARS OLD
THE SELECTED CHILD IS YOUNGER THAN AGE 15 (GO TO 60)

53) CHECK 41:

NO 'YES'
AT LEAST ONE 'YES' (GO TO 56)

54) Even if the child has not work in the last 7 days, does (NAME OF CHILD) has a job to which s/he has to return to?

YES 1
NO 2 (GO TO 59A)

55) What is the main reason (NAME OF CHILD) was absent from the job these past 7 days?

VACATION 01
WORK BREAK 02
MATERNITY LEAVE 03
SICKNESS 04
STRIKE 05
VOLUNTARY ABSENCE 06
TEMPORARY CONTRACT SUSPENSION 07
BEREAVEMENT LEAVE 08
RAIN 09
TRANSPORTATION PROBLEMS 10
SEASONAL WORK 11 (GO TO 59A)
ON CALL 12 (GO TO 59A)
STARTED OWN BUSINESS 13 (GO TO 59A)
OTHER REASON 96 (GO TO 59A)

56) What is the main activity in which (NAME OF CHILD) conducts his/her main job?

DESCRIBE THE MAIN ACTIVITY OF JOB/BUSINESS ____

57) What is the main task of (NAME OF CHILD) in his/her main job?

DESCRIBE THE MAIN TASK OF THE CHILD ____

58) In his/her main job, is (NAME OF CHILD) a permanent, temporary, seasonal or occasional worker?

PERMANENT 1
TEMPORARY 2
SEASONAL 3
OCCASIONAL 4

59) In his/her job does (NAME OF CHILD) earn money, in kind or is not remunerated?

EARNS MONEY 1 (GO TO 60)
EARNS MONEY AND IN KIND 2 (GO TO 60)
ONLY IN KIND 3 (GO TO 60)
IS NOT REMUNERATED 4 (GO TO 60)

59A) Is (NAME OF CHILD) available to work if a job was offered in the last 7 days?

YES 1
NO 2

59B) Did (NAME OF CHILD) look for a job in the last 30 days?

YES 1
NO 2

59C) Is (NAME OF CHILD) looking for a new job or a first job?

LOOKING FOR A NEW JOB 1
LOOKING FOR A FIRST JOB 2

SECTION 6A: WORK

60) CHECK THE AGE OF THE PERSONS IN COLUMN 7 IN THE LIST OF THE HOUSEHOLD QUESTIONNAIRE

AT LEAST ONE PERSON AGES 15-64 OR OLDER
NO PERSON AGES 15-64 (GO TO 101)

60A) CHECK 40:
IF THE PERSON IS 15-17 YEARS OLD AND WAS SELECTED FOR THE CHILD LABOR SECTION, S/HE SHOULD NOT BE RECORDED IN THE LIST BELOW.

61) FOR EACH PERSON AGES 15-64 WRITE THE LINE NUMBER OF COLUMN 1 OF THE HOUSEHOLD QUESTIONNAIRE

LINE NUMBER____

62) COPY THE NAME OF THE PERSON FROM COLUMN 2 OF THE HOUSEHOLD QUESTIONNAIRE

NAME___

WORK
63) In the last 7 days, did (NAME) work at least 1 hour in a remunerated work in money or kind?

YES 1 (GO TO 69)
NO 2

64) In the last 7 days did (NAME) work by his/her own (by him/herself or with other people) at least during 1 hour?

YES 1 (GO TO 69)
NO 2

65) In the last 7 days, did (NAME) helped in a family business without remuneration at least during 1 hour?

YES 1 (GO TO 69)
NO 2

66) In the last 7 days, did (NAME) work for the household's consumption without remuneration at least during 1 hour?

YES 1 (GO TO 69)
NO 2

67) Even if in the last 7 days (NAME) (has not worked in a remunerated job or by his/her own, or helped in the family business without payment), does s/he has a job to go back to?

YES 1
NO 2 (GO TO 73)

68) What is the main reason (NAME) was absent (in a remunerated work, or his/her own business or helping in a family business without payment), in the past 7 days?

VACATION 1
WORK BREAK 2
MATERNITY LEAVE 3
SICKNESS 4
STRIKE 5
VOLUNTARY ABSENCE 6
TEMPORARY CONTRACT SUSPENSION 7
BEREAVEMENT LEAVE 8
RAIN 9
TRANSPORTATION PROBLEMS 10
SEASONAL WORK 11
ON CALL 12
STARTED OWN BUSINESS 13
OTHER REASON 98

MAIN ECONOMIC ACTIVITY
69) What is the main activity in which (NAME) conducts his/her main job?

DESCRIBE THE MAIN ACTIVITY OF THE COMPANY/BUSINESS____

MAIN TASK
70) What is the main task (NAME) in his/her main job?

DESCRIBE THE MAIN TASK OF THE PERSON____

TYPE OF WORKER
71) In his/her main job, is (NAME) a permanent, temporary, seasonal or occasional worker?

PERMANENT 1
TEMPORARY 2
SEASONAL 3
OCCASIONAL 4

REMUNERATION
72) In his/her job does (NAME) earn money, in kind or is not remunerated?

EARNS MONEY 1
EARNS MONEY AND IN KIND 2
ONLY IN KIND 3
IS NOT REMUNERATED 4

AVAILABILITY TO WORK
73) Is (NAME) available to work if a job was offered in the last 7 days?

YES 1
NO 2

LOOKING FOR A JOB
74) Did (NAME) look for a job in the last 30 days?

YES 1
NO 2 (GO TO NEXT LINE)

75) Is (NAME) looking for a new job or a first job?

LOOKING FOR A NEW JOB 1
LOOKING FOR A FIRST JOB 2

SECTION 7: WATER, SANITATION AND OTHER HOUSEHOLD CHARACTERISTICS

101) What is the principal source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD 12 (GO TO 106)
PIPED INTO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP 14 (GO TO 106)
WELL WATER/ BOREHOLE
PROTECTED WELL 21 (GO TO 103)
UNPROTECTED WELL 21 (GO TO 103)
HOLE WITH PUMP 23 (GO TO 103)
WATER FROM SPRING
PROTECTED SPRING 31 (GO TO 103)
UNPROTECTED SPRING 32 (GO TO 103)
RAINWATER/RAINWATER RESERVOIR 41 (GO TO 103)
TANKER TRUCK 51 (GO TO 103)
(THREE WHEELED) MOTORCYCLE 61 (GO TO 103)
CART WITH SMALL TANK 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) ___ 96 (GO TO 103)

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD 12 (GO TO 106)
PIPED INTO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP 14
WELL WATER/ DUG WELL
PROTECTED WELL 21
UNPROTECTED WELL 22
HOLE WITH PUMP 23
WATER FROM SPRING
PROTECTED SPRING 31
UNPROTECTED SPRING 32
RAINWATER/RAINWATER RESERVOIR 41
TANKER TRUCK 51
(THREE WHEELED) MOTORCYCLE 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) ____ 96 (GO TO 103)

103) Where is that water source located?

IN OWN DWELLING 1 (GO TO 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

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

MINUTES___
DON'T KNOW 998

104A) Who in this household mostly gets the water?

GIRLS YOUNGER THAN 12 YEARS OLD A
BOYS YOUNGER THAN 12 YEARS OLD B
GIRLS AGES 12 THROUGH 17 C
BOYS AGES 12 THROUGH 17 D
WOMEN AGE 18 OR OLDER E
MEN AGE 18 OR OLDER F
NO ONE IN THE HOUSEHOLD G

105) CHECK 101 AND 102: CODE '14' CIRCLED?

YES
NO (GO TO 107)

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

YES 1
NO 2
DON'T KNOW 8

107) Do you do anything to treat drinking water?

YES 1
NO 2 (GO TO 109)
DON'T KNOW 8 (GO TO 109)

108) What do you usually do to treat drinking water?
Anything else?
RECORD ALL MENTIONED

BOIL A
ADD BLEACH/CHLORINE B
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) C
ANOTHER METHOD OF FILTERING WATER D
SOLAS DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY)___ X

109) Usually, what kind of toilet facility do members of your household use?

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

INSIDE THE HOUSE
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO OPEN CESSPIT (DITCH OR RIVER) 13
LATRINE FLUSH TO PIPED SEWER SYSTEM 14
LATRINE FLUSH TO SEPTIC TANK 15
OUTSIDE THE HOUSE BUT ON PLOT/YARD
FLUSH TO PIPED SEWER SYSTEM 21
FLUSH TO SEPTIC TANK 22
FLUSH TO OPEN CESSPIT (DITCH OR RIVER) 23
LATRINE FLUSH TO PIPED SEWER SYSTEM 24
LATRINE FLUSH TO SEPTIC TANK 25
LATRINE FLUSH TO OPEN CESSPIT (DITCH OR RIVER) 26
OUTSIDE PLOT/YARD
FLUSH TO PIPED SEWER SYSTEM 31
FLUSH TO SEPTIC TANK 32
FLUSH TO OPEN CESSPIT (DITCH OR RIVER) 33
LATRINE FLUSH TO PIPED SEWER SYSTEM 34
LATRINE FLUSH TO SEPTIC TANK 35
LATRINE FLUSH TO OPEN CESSPIT (DITCH OR RIVER) 36
BUCKET OR OTHER CONTAINER TOILET 41
NO FACILITY/BUSH/FIELD 61 (GO TO 113)
OTHER (SPECIFY)___ 96

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

YES 1
NO 2 (GO TO 112)

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

NUMBER OF HOUSEHOLDS IF LESS THAN 10 ____
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

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

ELECTRICITY 01
NATURAL GAS 02
OIL/PARAFFIN/ KEROSENE 03
COAL 04
WOOD/SHRUBS 05
STRAW/GRASS 06
CARDBOARD/PAPERBOARD 07
ANIMAL DUNG 08
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 115)
OTHER (SPECIFY)___ 96

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

INSIDE THE HOUSE
SEPARATE KITCHEN ROOM 1
COMMON AREA 2
SEPARATE BUILDING
SEPARATE KITCHEN ROOM 3
COMMON AREA 4
OUTDOORS 5
OTHER (SPECIFY)___ 96

115) What is the main source of lighting used in this household?

PUBLIC POWER LINES 01
POWER GENERATOR 02
SOLAR POWER 03
FLASHLIGHT 04
GAS OR OIL LAMP 05
CANDLES 06
LANTERN 07
FIREWOOD 08
DOES NOT HAVE LIGHTING 09
OTHER (SPECIFY)___ 96

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

ROOMS___

116A) How many rooms are in this household, not counting the bathroom or kitchen?

NUMBER OF ROOMS ____

117) Does this household own any livestock such as cattle or poultry?

YES 1
NO 2 (GO TO 119)

118) How many of the following animals does this household own?

IF NONE, RECORD '00'
IF 95 OR MORE, RECCORD '95'
IF UNKNOWN, RECORD '98'

Milk cows or bulls?
Goats?
Pigs?
Sheep?
Rabbits?
Chickens or ducks?

COWS/BULLS ___
GOATS__
PIGS____
SHEEP ___
RABBITS__
CHICKENS/DUCKS __

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

YES 1
NO 2 (GO TO 121)

120) How many hectares of agricultural land do members of this household own?

IF 95 OR MORE, CIRCLE '950'

HECTARES_____
95 OR MORE HECTARES 950
DON'T KNOW 998

121) Does your household have?
Electricity?
A radio?
A television?
A non-mobile telephone?
A computer?
A refrigerator?
Internet access?

ELECTRICITY
YES 1
NO 2
RADIO
YES 1
NO 2
TELEVISION
YES 1
NO 2
NON-MOBILE TELEPHONE
YES 1
NO 2
COMPUTER
YES 1
NO 2
REFRIGERATOR
YES 1
NO 2
INTERNET
YES 1
NO 2

122) Does any member of this household own:

A watch?
A mobile phone?
A bicycle?
A motorcycle?
An animal-drawn cart?
A car or truck?
A boat with motor?

WATCH
YES 1
NO 2
MOBILE PHONE
YES 1
NO 2
BICYCLE
YES 1
NO 2
MOTORCYCLE
YES 1
NO 2
ANIMAL-DRAWN CART
YES 1
NO 2
CAR/TRUCK
YES 1
NO 2
BOAT WITH MOTOR
YES 1
NO 2

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

YES 1
NO 2

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

DAILY 1
WEEKLY 2
MONTHLY 3
LESS OFTEN THAN ONCE A MONTH 4
NEVER 5

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

YES 1
NO 2 (GO TO 127)
DON'T KNOW 8 (GO TO 127)

126) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY)___ X
DON'T KNOW Z

127) Does your household have any mosquito nets for when you sleep?

YES 1
NO 2 (GO TO 139)

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

NUMBER OF NETS_____

SECTION 8: MOSQUITO NETS

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

HOLES OBSERVED 1
NO HOLES OBSERVED 2
NOT OBSERVED 3

130) How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'

MONTHS AGO___
36 OR MORE MONTHS AGO 95
DON'T KNOW 98

131) OBSERVE OR ASK THE 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
JOIA 11 (GO TO 134)
OLYSET 12 (GO TO 134)
PERMANENT 13 (GO TO 134)
YORKOO 14 (GO TO 134)
OTHER/DON'T KNOW BRAND 15 (GO TO 134)
UNTREATED NET
OTHER BRAND 96
DON'T KNOW TYPE 98

131A) Since you got the net, was it treated to kill or repel mosquitoes?

YES 1
NO 2
DON'T KNOW 8

132) Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?

YES 1
NO 2 (GO TO 134)
DON'T KNOW 8 (GO TO 134)

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

MONTHS___
24 OR MORE MONTHS AGO 95
DON'T KNOW 98

134) Did you get the net through a national distribution campaign, during antenatal care visit or during an immunization visit?

YES, DISTRIBUTION CAMPAIGN 1 (GO TO 136)
YES, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4

135) Where did you get the net?

PUBLIC HEALTH POST 1
PRIVATE HEALTH POST 2
PHARMACY 3
SHOP/MARKET 4
HEALTH WORKER 5
RELIGIOUS INSTITUTION 6
OTHER 7
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 138)
DON'T KNOW 8 (GO TO 138)

137) Who slept under this mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME____
LINE NUMBER ___

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

SECTION 9: HOUSEHOLD CHARACTERISTICS

139) Can you please show me where the members of your household most often wash their hands?
Can I see it?

OBSERVED 1
NOT OBSERVED
NOT IN DWELLING 2 (GO TO 142)
NO PERMISSION TO SEE 3 (GO TO 142)
OTHER REASON (REASON) ________ 6 (GO TO 142)

140) RECORD OBSERVATION:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

141) RECORD OBSERVATION:
OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANING AGENT AT THE PLACE FOR HANDWASHING.

SOAP OR DETERGENT (BAR, LIQUID, POWDER) A
ASH, MUD, SAND B
NONE C

142) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING
RECORD OBSERVATION

NATURAL FLOOR
EARTH/SAND 11
RUDIMENTARY FLOOR
WOOD PLANKS 21
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CERAMIC TILES 32
CEMENT 33
MARBLE/GRANITE 34
OTHER (SPECIFY)___ 96

143) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING
RECORD OBSERVATION

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
PALM/BAMBOO 21
WOOD PLANKS 22
CARDBOARD 23
FINISHED ROOFING
METAL ROOF 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CONCRETE SLAB 35
ROOFING SHINGLES 36
OTHER (SPECIFY)___ 96

144) OBSERVE MAIN MATERIALS OF THE EXTERIOR WALLS OF THE DWELLING
RECORD OBSERVATION

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
MUD WALL 21
STONE WITH MUD 22
ADOBE 23
WOOD 24
ALUMINUM/CARDBOARD/PAPER/ PLASTIC 25
METAL SHEET 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS 35
OTHER (SPECIFY)___ 96

145) 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

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) ____ 6

146) RECORD TIME

HOURS _____
MINUTES____

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:__________________

COMMENTS ON SPECIFIC QUESTIONS:_________________

ANY OTHER COMMENTS:___________

SUPERVISOR'S OBSERVATIONS _______________________________________