IDENTIFICATION
REGION
DIVISION
SUB-DIVISION
LOCALITY
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
HOUSEHOLD SELECTED FOR MAN'S SURVEY?

INTERVIEWER VISITS
DATE
INTERVIEWER'S NAME
RESULT

FINAL VISIT
DAY
MONTH
YEAR
INT. NO
RESULT

NEXT VISIT
DATE
TIME

TOTAL NUMBER 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

INTERPRETER USED

TEAM LEADER

CONTROLLER

INTRODUCTION AND CONSENT

Hello, My name is _____ I am working with the NATIONAL INSTITUTE OF STATISTICS. In collaboration with the MINISTRY OF PUBLIC HEALTH, we are conducting a survey about health and other topics all over CAMEROON. 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 questions 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.

SIGNATURE OF THE INTERVIEWERS __________
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 5-20A FOR EACH PERSON.

2A. Just to make sure that I have a complete listing, are there any other people such as small children or infants that we have not listed?

2B. Are there any other people who may 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?

5. RESIDENCE: Does (NAME) usually live here?

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

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

IF AGE 0-6 YEARS

7A. What is (NAME)'s date of birth? On what day, month, and year was (NAME) born?
IF DON'T KNOW DAY, RECORD 98
IF DON'T KNOW MONTH, RECORD 98
IF DON'T KNOW YEAR, RECORD 9998

IF AGE 10 OR OLDER

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

ELIGIBILITY

9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-64

10. IF HOUSEHOLD SELECTED FOR MAN'S SURVEY. CIRCLE LINE NUMBER OF ALL MEN AGE 15-64

11. IF HOUSEHOLD NOT SELCTED 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

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 3 YEARS OR OLDER: EVER ATTENDED SCHOOL

16. Has (NAME) ever attended school or nursery/cpc school?

17. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at this level?
SEE CODES BELOW

IF AGE 3-24 YEARS: CURRENT/RECENT SCHOOL ATTENDANCE

18. Did (NAME) attend school or nursery/cpc school at any time during the 2017-2018 school year?

19. During the 2017-2018 school year, what level and grade is/was (NAME) attending?
SEE CODES BELOW

PREVIOUS SCHOOL ATTENDANCE

18A. Did (NAME) attend school or nursery/cpc school at any time during the previous school year, that is 2016-2017 school year?

19A. During the 2017-2017 school year, what level and grade was (NAME) attending?
SEE CODES BELOW

IF AGE 0-17 YEARS

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

IF AGE 0-4 YEARS

20A. AGE IN MONTHS AT BIRTH REGISTRATION: How long after (NAME)'s birth his/her birth was registered with the civil authority?

101. 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 handwashing?

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. 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 MAINLLY 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, 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, CIRCLE 950

121. Does your household have:

122. Does any member of this household own:

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

123a. Does any member of this household have an account in another financial institution?

124. How often does anyone smoke inside your house? would you say daily, weekly, monthly,

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 ALL 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 BRAND/TYPE OF MOSQUITO NET.
IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPE/BRANDS TO RESPONDENT.

134. Did you get the net through the 2011-2012 distribution campaign, 2015-2016 distribution campaign, during an antenatal care visit, or during an immunization visit?

135. Where did you get the net?

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

138. GO BACK TO 129 FOR NEXT NET OR, IF NO MOR ENETS, GO TO 139.

139. We would like to learn more 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 HANDWASHING. RECORD OBSERVATION.

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

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

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

144. OBSERVER MAIN MATERIAL 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?

145A. TESTING FOR PRESENCE FOR POTASSIUM IODATE

145B. TESTING FOR PRESENCE OF POTASIUM IODIDE

SELECTION OF WOMAN AND MAN FOR THE DOMESTIC VIOLENCE QUESTIONS (PAPER OPTION)

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IIN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW _____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS ______

SUPERVISOR'S OBSERVATIONS _____
EDITOR'S OBSERVATIONS ____