IDENTIFICATION

PLACE NAME

NAME OF HEAD OF HOUSEHOLD

PROVINCE

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MEN'S SURVEY?

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER'S NAME
RESULT

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR
INT. NUMBER
RESULT

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONNAIRE

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED

LANGUAGE OF QUESTIONNAIRE:

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___________

100) RECORD THE TIME.

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?

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?

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

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

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

RESIDENCE:

5) Does (NAME) usually live here?

6) Did (NAME) stay here last night?

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

IF AGE 15 OR OLDER:

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

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?

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?

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?

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:

IF AGE 3 YEARS OR OLDER:

EVER ATTENDED SCHOOL:

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

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.

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?

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

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?

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

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?

IF 0-2 YEARS:

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

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

TICK HERE IF CONTINUATION SHEET USED___

HOUSEHOLD CHARACTERISTICS

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

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

103) Where is the water source located?

104) How long does it take you 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) 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 this toilet 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) How many of the following animals does this household own?

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

121) Does your household have:

122) Does any member of your household own:

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

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

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

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

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

126) How sprayed the dwelling?

127) Does your household have any mosquito nets?

128) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD 7.

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

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

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.

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

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

IF LESS THAN ONE MONTH AGO, RECORD 00.

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?

135) Where did you get the mosquito net?

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

137) Who slept under the mosquito net last night?

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

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?

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

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

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

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

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

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.

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.

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

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:

154) LINE NUMBER FROM COLUMN 1

155) NAME FROM COLUMN 2

156) SEX FROM COLUMN 4

157) AGE FROM COLUMN 7

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:

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?

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.

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

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.

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

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

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

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

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.

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

170) CHECK 167 A-G:

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

CHILD DISCIPLINE

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

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

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.

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

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:

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:

____________________________________