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REPUBLIC OF BURUNDI THIRD DEMOGRAPHIC AND HEALTH SURVEY 2016 HOUSEHOLD QUESTIONNAIRE

IDENTIFICATION

PLACE NAME

NAME OF HEAD OF HOUSEHOLD

PROVINCE

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MEN’S SURVEY?

YES 1
NO 2

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER’S NAME
RESULT

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)

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

TOTAL NO. OF VISITS

TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

YES 1
NO 2

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE CODES:

01 FRENCH
96 OTHER (SPECIFY)
OLD KIRUNDI (FROM PAPER)

SUPERVISOR
NAME
NUMBER

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the Institute of Statistics and Economic Study of Burundi, ISTEEBU. We are conducting a survey about health and other topics all over Burundi. 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. In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

SIGNATURE OF INTERVIEWER________________
DATE___________

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

100) RECORD THE TIME.

HOURS___
MINUTES___

HOUSEHOLD SCHEDULE

1) LINE NUMBER

________

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.

Just to make sure that I have a complete listing:

2A) Are there any other persons such as small children or infants that we have not listed?

YES (ADD EACH IN TABLE)
NO

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

YES (ADD EACH IN TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

YES (ADD EACH IN TABLE)
NO

3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

CODING:

01= HEAD
02= WIFE OR HUSBAND
03= SON OR DAUGHTER
04= SON-IN-LAW OR DAUGHTER-IN-LAW
05= GRANDCHILD
06= PARENT
07= PARENT-IN-LAW
08= BROTHER OR SISTER
09= OTHER RELATIVE
10= ADOPTED/FOSTER/STEPCHILD
11= NOT RELATED
98= DON’T KNOW

4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

RESIDENCE:

5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

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

YEARS___

IF AGE 15 OR OLDER:

8) MARITAL STATUS: What is (NAME)’s current marital status?

1=MARRIED OR LIVING TOGETHER
2=DIVORCED/SEPARATED
3=WIDOWED
4=NEVER MARRIED AND NEVER LIVED TOGETHER

ELIGIBILITY:

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

10) IF HOUSEHOLD SELECTED FOR MAN’S SURVEY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

11) IF HOUSEHOLD SELECTED FOR MAN’S SURVEY: 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?

YES 1
NO 2 (GO TO 13A)
DON'T KNOW 8 (GO TO 13A)

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.

13A) IF Q. 13= 00: Where does (NAME)’s biological mother live?

CODING:

1=OTHER HOUSEHOLD IN BURUNDI
2=INSTITUTION IN BURUNDI
3=COUNTRY BORDERING BURUNDI
4=OTHER COUNTRY
8=DON’T KNOW

13B) IF Q. 13 BLANK OR 00: Who is (NAME)’s primary guardian?

RECORD LINE NUMBER OF THE GUARDIAN.

14) Is (NAME)’s natural father alive?

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

15) Does (NAME)’s natural father 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.

15A) IF Q. 15= 00: Where does (NAME)’s biological father live?

CODING:

1=OTHER HOUSEHOLD IN BURUNDI
2=INSTITUTION IN BURUNDI
3=COUNTRY BORDERING BURUNDI
4=OTHER COUNTRY
8=DON’T KNOW

IF AGE 3 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

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

YES 1
NO 2 (GO TO 20)

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

IF THEY HAVEN’T COMPLETED ANY GRADE IN A LEVEL, RECORD 00.

LEVEL___
GRADE___

SEE CODES BELOW.

IF AGE 3-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school or nursery school at any time during the (2016-2017) school year?

YES 1
NO 2 (GO TO 20)

19) During the 2016-2017 school year, what level and grade (is/was) (NAME) attending?

LEVEL___
GRADE___

SEE CODES BELOW.

IF 3-24 YEARS:

PREVIOUS SCHOOL ATTENDANCE:

18A) Has (NAME) ever attend school or nursery school at any time during the 2016-2017 school year?

YES 1
NO 2 (GO TO 20)

19A) During the 2016-2017 school year, what level and grade is/was (NAME) attending?

LEVEL___
GRADE___

SEE CODES BELOW.

DES REGISTRATION:

IF 0-35 YEARS:

20) Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)’s birth ever been registered with the civil authority?

1=HAS CERTIFICATE
2=REGISTERED
3=NEITHER
8=DON’T KNOW

IF 0-2 YEARS:

21) What were the documents produced for the registration with the civil authority?

1=MOTHER INFANT BOOKLET
2=MEDICAL CERTIFICATE
3=REGISTERED WITHOUT BOOKLET OR CERTIFICATE
4=NOT REGISTERED
8=DON’T KNOW

CODES FOR Q 17, 19, AND 19A: EDUCATION

LEVEL
0=PREPRIMARY
1=PRIMARY
2=SECONDARY 1ST CYCLE
3=SECONDARY 2ND CYCLE
4=HIGHER
8=DON’T KNOW
GRADE
PRIMARY
1=1ST YEAR
2=2ND YEAR
3=3RD YEAR
4=4TH YEAR
5=5TH YEAR
6=6TH YEAR
8=DON’T KNOW
SECONDARY 1ST CYCLE
1=7TH YEAR
2=8TH YEAR
3=9TH YEAR
4=10TH YEAR
8=DON’T KNOW
SECONDARY 2ND CYCLE
1=11TH YEAR
2=12TH YEAR
3=13TH YEAR
4=14TH YEAR
8=DON’T KNOW
HIGHER
1=1ST YEAR
2=2ND YEAR
3=3RD YEAR
4=4TH YEAR OR HIGHER
8=DON’T KNOW

TICK HERE IF CONTINUATION SHEET USED___

HOUSEHOLD CHARACTERISTICS

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

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED INTO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
TUBE WELL OR BOREHOLD 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 103)
TANKER TRUCK 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) Where 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 INTO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLD 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY) 96

103) Where is the 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 you to go there, get water, and come back?

MINUTES___
DON’T KNOW 998

105) CHECK 101 AND 102: CODE 14 OR 21 CIRCLED:

YES (GO TO 106)
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 the water to make it safer to drink?

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

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

RECORD ALL MENTIONED.

BOIL A
ADD BLEACH/CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
OTHER (SPECIFY) X
DON’T KNOW Z

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

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

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON’T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
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?

NO. OF HOUSEHOLDS IF LESS THAN 10___
10 OR MORE HOUSEHOLDS 95
DON’T KNOW 98

112) Where is this toilet facility located?

IN OWN DWELLING 1
IN OWN YARD/PLOT 2
ELSEWHERE 3

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

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11

NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 116)
OTHER (SPECIFY) 96

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

IN THE HOUSE 1 (GO TO 116)
IN A SEPARATE BUILDING 2 (GO TO 116)
OUTDOORS 3 (GO TO 116)
OTHER (SPECIFY) 6 (GO TO 116)

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

YES 1
NO 2

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

ROOMS___

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

YES 1
NO 2 (GO TO 119)

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

IF NONE, ENTER 00. IF 95 OR MORE, ENTER 95. IF UNKNOWN, ENTER 98

a) Milk cows or bulls?
NUMBER___
b) Other cattle?
NUMBER___
c) Horses, donkeys, or mules?
NUMBER___
d) Goats?
NUMBER___
e) Sheep?
NUMBER___
f) Pigs?
NUMBER___
g) Poultry (Chickens, ducks, pigeons, turkey, Guinea fowl)?
NUMBER___
h) Rabbits?
NUMBER___
i) Guinea pig
NUMBER___

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

YES 1
NO 2

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

HECTARES_____
95 OR MORE HECTARES 950
DON’T KNOW 998

121) Does your household have:

a) Electricity?
YES 1
NO 2
b) A radio?
YES 1
NO 2
c) A television?
YES 1
NO 2
d) A non-mobile telephone?
YES 1
NO 2
e) A computer (portable or not)?
YES 1
NO 2
f) A refrigerator?
YES 1
NO 2
g) A dining room table?
YES 1
NO 2
h) Chairs?
YES 1
NO 2
i) A wardrobe?
YES 1
NO 2
j) A stepladder?
YES 1
NO 2
k) A mattress?
YES 1
NO 2
l) A hoe?
YES 1
NO 2

122) Does any member of your household own:

a) A watch?
YES 1
NO 2
b) A mobile phone?
YES 1
NO 2
c) A bicycle?
YES 1
NO 2
d) A motorcycle or motor scooter?
YES 1
NO 2
e) An animal-drawn cart?
YES 1
NO 2
f) A car or truck?
YES 1
NO 2
g) A boat with a motor?
YES 1
NO 2

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

YES 1
NO 2

123A) If you had to get to the closest health center, what mode of transportation would you use?

PRIVATE CAR/MOTORBIKE 1
PUBLIC TRANSPORTATION (BUS, TAXI, MOTORBIKE) 2
BY FOOT 3
BIKE 4
OTHER (SPECIFY) 6

123B) How long would it take you to get to the closest health center using (MODE OF TRANSPORTATION FROM Q. 123A)?

MINUTES____
DON’T KNOW 998

124) Does anyone in your household smoke? Would you say daily, weekly, monthly, less than monthly, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 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) How 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?

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___

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

OBSERVED 1
NOT OBSERVED 2

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

MONTHS AGO___
MORE THAN 36 MONTHS AGO 95
NOT SURE 97

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 (LLIN)
OLYSET 11 (GO TO 134)
INTERCEPTOR 12 (GO TO 134)
PERMANET 13 (GO TO 134)
OTHER/DK BRAND 16 (GO TO 134)
OTHER BRAND 96
DON'T KNOW BRAND 98

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

YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD 00.

MONTHS AGO___
MORE THAN 24 MONTHS AGO 95
NO SURE 98

134) Did you get the net through a) the distribution campaign in 2009, b) the campaign in 2010, c) the campaign in 2011, d) the campaign in 2014, e) during a prenatal consultation or during a delivery, f) while getting a vaccine for a child, or g) another occasion?

YES, THE DISTRIBUTION CAMPAIGN IN 2009 1 (GO TO 136)
YES, THE CAMPAIGN IN 2010 2 (GO TO 136)
YES, THE CAMPAIGN IN 2011 3 (GO TO 136)
YES, THE CAMPAIGN IN 2014 4 (GO TO 136)
YES, DURING A PRENATAL CONSULTATION OR DURING A DELIVERY 5 (GO TO 136)
YES, WHILE GETTING A VACCINE FOR A CHILD 6 (GO TO 136)
YES, ANOTHER OCCASION 7 (GO TO 136)

NO 8

135) Where did you get the mosquito net?

GOVERNMENT HEALTH FACILITY 01
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
OTHER 96
DON’T KNOW 98

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 the 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.

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

OBSERVED, FIXED PLACE 1
OBSERVED, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (GO TO 142)
NOT OBSERVED, NO PERMISSION TO SEE 4 (GO TO 142)
NOT OBSERVED, OTHER REASON 5 (GO TO 142)

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

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

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

SOAP OR DETERGENT (IN A PIECE, POWDER, OR LIQUID) A
ASH, MUD, SAND B
NONE Y

142) OBSERVE MAIN MATERIALS OF THE FLOOR IN THE DWELLING. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96

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

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED FLOORING
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 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
BAMBOO/CANE/PALM/TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 21
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
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

SELECTION OF ONE CHILD FOR CHILDREN’S WORK/DISCIPLINE:

150) CHECK COLUMN 7 IN THE LIST OF HOUSEHOLD MEMBERS AND RIGHT THE TOTAL NUMBER OF CHILDREN AGE 1-17 YEARS.

TOTAL NUMBER___

151) CHECK THE NUMBER OF CHILDREN AGE 1-17 IN 150:

ZERO (GO TO 177)

ONE (GO TO 159 AND RECORD THE RANK NUMBER AS 1, ENTER THE LINE NUMBER, THE CHILD’S NAME, AND HIS OR HER AGE.)

TWO OR MORE (GO TO 152)

152) LIST EACH CHILD AGE 1-17 YEARS FROM THE HOUSEHOLD SCHEDULE IN THE TABLE BELOW IN THE ORDER THEY APPEAR IN THE LIST OF HOUSEHOLD MEMBERS. DO NOT INCLUDE MEMBERS OF THE HOUSEHOLD WHOSE AGE IS OUTSIDE OF 1-17 YEARS. RECORD THE LINE NUMBER, NAME, SEX AND AGE FOR EACH CHILD.

153) RANK NUMBER:

RANK___

154) LINE NUMBER FROM COLUMN 1

LINE___

155) NAME FROM COLUMN 2

NAME__________

156) SEX FROM COLUMN 4

MALE
FEMALE

157) AGE FROM COLUMN 7

AGE

158) CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER RECORDED ON THE COVER PAGE. THIS IS THE LINE NUMBER IN THE TABLE BELOW FROM WHICH YOU MUST CHECK THE TOTAL NUMBER OF CHILDREN (Q150) ON THE PREVIOUS PAGE. THIS IS THE COLUMN NUMBER FROM THE TABLE BELOW THAT YOU SHOULD GO TO.

FIND THE BOX WHERE THE LINE AND COLUMN INTERSECT AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE NUMBER OF THE RANK NUMBER OF THE CHILD SELECTED FOR CHILD LABOR/DISCIPLINE FROM THE BOX OF ELIGIBLE CHILDREN IN Q. 153.
RECORD THE RANK NUMBER, THE LINE NUMBER, THE AGE, AND THE NAME OF THE CHILD SELECTED IN THE SPACE BELOW.

EXAMPLE: THE HOUSEHOLD NUMBER IS 716 AND Q 151 SHOWS THAT THERE ARE THREE ELIGIBLE CHILDREN AGED 1-17 IN THE HOUSEHOLD. SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS 6, GO TO LINE 6 AND SINCE THERE ARE THREE ELIGIBLE CHILDREN, GO TO COLUMN 3. FIND THE BOX WHERE THE LINE AND THE COLUMN INTERSECT (2) AND CIRCLE THE NUMBER. NOW GO TO Q 153 AND FIND THE SECOND CHILD. WRITE THE NAME, AGE, LINE NUMBER, AND RANK OF THE CHILD IN THE SPACE BELOW.

LAST DIGIT FROM HOUSEHOLD NUMBER___
TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 1-17 IN THE HOUSEHOLD FROM Q 151___

159) NAME OF CHILD SELECTED_____________
AGE OF CHILD SELECTED___
LINE NUMBER OF CHILD SELECTED___
RANK NUMBER OF CHILD SELECTED___

CHILDREN’S WORK

160) CHECK AGE OF CHILD SELECTED FROM 159:

5-17 YEARS (GO TO 161)
1-4 YEARS (GO TO 172)

161) Now I would like to talk about all the work the children in this household can do. Since the last (DAY OF THE WEEK), did (NAME) do any of the following activities, even if it was just for an hour?

a) Did (NAME) work on his/her own or help with a household member’s field/farm/vegetable garden or take care of animals. For example, work with farm products, harvest, feed animals, take animal to pasture, or milk them?
YES 1
NO 2
b) Did (NAME) help with the family business, the business of other relatives with or without payment or worked in his or her own business?
YES 1
NO 2
c) Did (NAME) produce, sell goods, artisanal products, clothes, food, or agricultural products?
YES 1
NO 2
d) Since last (DAY OF THE WEEK), did (NAME) engage in any other activity in exchange for payment in case or in kind, even if only for an hour?
YES 1
NO 2

IF NO, PROBE: Please, include any type of activity that (NAME) could have done as a regular or temporary job, for his/her own business or as employee, or as unpaid family employee to help in household or farm work.

d) ALL OTHER ACTIVITY
YES 1
NO 2

162) CHECK 161, (a), A, (d):

AT LEAST ONE YES (GO TO 163)
NOT A SINGLE YES (GO TO 167)

163) Since last (DAY OF THE WEEK), approximately how many hours total did (NAME) do work in this activity/these activities? IF LESS THAN 1 HOUR, RECORD 00.

NUMBER OF HOURS___

164) Does/do this activity/these activities require carrying heavy loads?

YES 1 (GO TO 167)
NO 2

165) Does/do this activity/these activities require working with dangerous tools (knives, etc.) or to operate heavy machinery?

YES 1 (GO TO 167)
NO 2

166) How would you describe (NAME)’s work environment?

a) Is (NAME) exposed to dust/smoke or gas?
YES 1 (GO TO 167)
NO 2
b) Is (NAME) exposed to cold, heat, or excessive humidity?
YES 1 (GO TO 167)
NO 2
c) Is (NAME) exposed to loud noises or vibrations?
YES 1 (GO TO 167)
NO 2
d) Is (NAME) exposed to working at high heights?
YES 1 (GO TO 167)
NO 2
e) Is (NAME) exposed to chemical products (pesticides, glues, etc) or to explosives?
YES 1 (GO TO 167)
NO 2
f) Is (NAME) exposed to other things, behaviors, or conditions that are bad for his/her behavior or security?
YES 1
NO 2

167) Since last (DAY OF WEEK), did name fetch water or firewood for the household?

YES 1
NO 2 (GO TO 169)

168) In total, since last (DAY OF WEEK), how many hours did (NAME) spend fetching water or firewood for the household? IF LESS THAN ONE HOUR, RECORD 00.

NUMBER OF HOURS___

169) Since last (DAY OF WEEK), did (NAME) do any of the following tasks for the household?

a) make purchases for the household?
YES 1
NO 2
b) fix any type of equipment for the household?
YES 1
NO 2
c) cook or clean utensils or the house?
YES 1
NO 2
d) wash clothing?
YES 1
NO 2
e) take care of children?
YES 1
NO 2
f) take care of elderly or sick people?
YES 1
NO 2
g) other tasks for the household?
YES 1
NO 2

170) CHECK 167 A-G:

AT LEAST ONE YES (GO TO 171)
NOT A SINGLE YES (GO TO 172)

171) Since last (DAY OF WEEK OF INTERVIEW), about how many hours in total did (NAME) spend doing these activities?

NUMBER OF HOURS___

CHILD DISCIPLINE

172) CHECK AGE OF CHILD SELECTED FOR Q. 159:

1-14 YEARS (GO TO 173)
15-17 YEARS (GO TO NEXT MODULE)

173) WRITE THE NAME AND LINE NUMBER OF THE CHILD FROM Q. 159.

LINE NUMBER ____
NAME ____________

174) Adults use certain ways to teach children the right behavior or to address a behavior problem. I will read various methods that are use. Please tell me if you or anyone else in the household has used this method with (NAME) in the past month.

a) Took away privileges, forbade something (NAME) liked or did not allow (him/her) to leave the house.
YES 1
NO 2
b) Explained why (NAME)'s behavior was wrong.
YES 1
NO 2
c) Shook (him/her)
YES 1
NO 2
d) Shouted, yelled at or screamed at (him/her)
YES 1
NO 2
e) Gave (him/her)something else to do.
YES 1
NO 2
f) Spanked, hit or slapped (him/her) on the bottom with bare hand.
YES 1
NO 2
g) Hit (him/her) on the bottom or elsewhere on the body with something like a belt, hairbrush, stick, or other hard object.
YES 1
NO 2
h) Called (him/her) dumb, lazy, or another name like that.
YES 1
NO 2
i) Hit or slapped (him/her) on the face, head, or ears.
YES 1
NO 2
j) Hit or slapped (him/her) on the hand, arm, or leg.
YES 1
NO 2
k) Beat him/her up, that is hit (him/her) over as hard as one could.
YES 1
NO 2

175) Do you believe that in order to bring up, raise, or educate a child properly, the child needs to be physically punished?

YES 1
NO 2
DON'T KNOW/NO OPINION 8

SELECTION TABLE FOR WOMEN AND MEN FOR THE DOMESTIC VIOLENCE MODULE

CHECK THE LAST DIGIT OF THE HOUSEHOLD NUMBER RECORDED ON THE COVER PAGE. THIS IS THE LINE NUMBER IN THE TABLE BELOW FROM WHICH YOU MUST CHECK THE TOTAL NUMBER OF WOMEN AND MEN ELIGIBLE (COLUMNS 9 AND 10) ON THE PREVIOUS PAGE. THIS IS THE COLUMN NUMBER FROM THE TABLE BELOW THAT YOU SHOULD GO TO.

FIND THE BOX WHERE THE LINE AND COLUMN INTERSECT AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS IS THE ORDER NUMBER OF THE PERSON SELECTED TO RESPOND TO THE QUESTIONS ON DOMESTIC VIOLENCE FROM THE LIST OF ELIGIBLE WOMEN AND MEN IN COLUMN 9 OR 10 OF THE HOUSEHOLD TABLE.

RECORD THE NAME AND LINE NUMBER OF THE PERSON SELECTED IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD NUMBER IS 716 AND COLUMNS 9 AND 10 OF THE HOUSEHOLD SCHEDULE SHOWS THAT THERE ARE THREE ELIGIBLE PEOPLE (WOMEN AGED 15-49 AND MEN AGED 15-59) IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS 6, GO TO LINE 6 AND SINCE THERE ARE THREE ELIGIBLE PEOPLE IN THE HOUSEHOLD, GO TO COLUMN 3. FIND THE BOX WHERE THE LINE AND THE COLUMN INTERSECT (2) AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD TABLE AND FIND THE SECOND ELIGIBLE PERSON (WOMAN OR MAN).

LAST DIGIT OF THE SERIES NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE ____
TOTAL NUMBER OF ELIGIBLE WOMEN AND MEN IN COLUMN 9 OR 10 OR THE HOUSEHOLD TABLE_____

176) NAME OF PERSON SELECTED______________
LINE NUMBER IN THE HOUSEHOLD TABLE OF PERSON SELECTED___

177) RECORD THE TIME:

HOURS___
MINUTES___

INTERVIEWER’S OBSERVATIONS TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT THE INTERVIEW:

____________________________________

COMMENTS ON SPECIFIC QUESTIONS:

____________________________________

ANY OTHER COMMENTS:

____________________________________

SUPERVISOR’S OBSERVATIONS:

____________________________________

EDITOR’S OBSERVATIONS:

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