REPUBLIQUE DU CAMEROON
NATIONAL INSTITUTE OF STATISTICS
IDENTIFICATION
REGION
DIVISION
SUB-DIVISION
LOCALITY
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
HOUSEHOLD SELECTED FOR MAN'S SURVEY?
NO 2
INTERVIEWER VISITS
DATE
INTERVIEWER'S NAME
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_______ 7
FINAL VISIT
DAY
MONTH
YEAR
INT. NO
RESULT
NOT AT HOME 2
POSTPONED 3
REFUSED 4
PARTLY COMPLETED 5
INCAPACITATED 6
OTHER (SPECIFY)_______ 7
NEXT VISIT
DATE
TIME
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)__________ 96
LANGUAGE OF INTERVIEW
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)__________ 96
NATIVE LANGUAGE OF RESPONDENT
FRENCH 02
FUFULDE 03
EWONDO 04
PIDGIN 05
OTHER (SPECIFY)__________ 96
INTERPRETER USED
NO 2
NUMBER
CONTROLLER
NUMBER
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 ________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES____
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?
NO
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?
NO
2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON IN LAW OR DAUGHTER IN LAW 04
GRANDCHILD 05
PARENT 06
PARENT IN LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. RESIDENCE: Did (NAME) stay here last night?
NO 2
7. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD 95.
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
MONTH ___
YEAR ___
8. MARITAL STATUS: What is (NAME)'s current marital status?
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED AND NEVER LIVED TOGETHER 4
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?
NO 2 (GO TO 14)
DK 8 (GO TO 14)
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?
NO 2 (GO TO 16)
DK 8 (GO TO 16)
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?
NO 2 (GO TO 20)
17. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at this level?
SEE CODES BELOW
GRADE __
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?
NO 2 (GO TO 18A)
19. During the 2017-2018 school year, what level and grade is/was (NAME) attending?
SEE CODES BELOW
GRADE ___
18A. Did (NAME) attend school or nursery/cpc school at any time during the previous school year, that is 2016-2017 school year?
NO 2 (GO TO 20)
19A. During the 2017-2017 school year, what level and grade was (NAME) attending?
SEE CODES BELOW
GRADE __
20. BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
20A. AGE IN MONTHS AT BIRTH REGISTRATION: How long after (NAME)'s birth his/her birth was registered with the civil authority?
1 MONTH 1
2 MONTHS 2
3 OR MORE MONTHS 3
DON'T KNOW 8
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (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
SACHET WATER 92
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 TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER 91
SACHET WATER 92
OTHER __(SPECIFY)__ 96
103. Where is that water source located?
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. CHECK 101 AND 102. CODE 14 OR 21 CIRCLED?
NO (GO TO 107)
106. In the past two weeks, was the water from this source not available for at least one full day?
NO 2
DON'T KNOW 8
107. Do you do anything to the water to make it safer to drink?
NO 2
DON'T KNOW 109
108. What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED.
ADD BLEACH/CHLORINE B
STRAIN THROUGH 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 TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET 51
NO FACILITY/BUSH/FIELD 61 (GO TO 113)
OTHER (SPECIFY) 96
110. Do you share this toilet facility with other households?
NO 2 (GO TO 112)
111. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
112. Where is this toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE 3
113. WHAT TYPE OF FUEL DOES YOUR HOUSEHOLD MAINLLY USE FOR COOKING?
LPG 02
NATURLA GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
SAWDUST/WOOD CHIPS
NO FOOD COOKED IN HOUSEHOLD 96 (GO TO 116)
OTHER (SPECIFY) 96
114. Is the cooking usually done in the house, in a separate building, or outdoors?
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?
NO 2
116. How many rooms in this household are used for sleeping?
117. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 119)
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
OTHER CATTLE __
HORSES/DONKEYS/MULES __
GOATS __
SHEEP __
PORK __
CHICKENTS/POULTRY __
119. Does any member of this household own any agricultural land?
NO 2 (GO TO 121)
120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950
05 OR MORE HECTARES 950
DON'T KNOW 998
121. Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
122. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
123. Does any member of this household have a bank account?
NO 2
123a. Does any member of this household have an account in another financial institution?
NO 2
124. How often does anyone smoke inside your house? would you say daily, weekly, monthly,
NO 2
127. Does your household have any mosquito nets?
NO 2
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).
NOT OBSERVED 2
130. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD 00
MORE THAN 36 MONTHS AGO 95
NOT SURE 98 __
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.
OLYSET 11
PERMANET 12
DURANET 13
INTERCEPTC 14
NET PROTEC 15
OTHER/DON'T KNOW BRAND 16
OTHER TYPE 96
DON'T KNOW TYPE 98
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?
YES 2015-2016 CAMPAIGN 2 (SKIP TO 136)
YES ANC 3 (SKIP TO 136)
YES IMMUNIZATION VISIT 4 (SKIP TO 136)
NO 5
135. Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
SCHOOL 07
RELATIVE/ FRIEND 08
OTHER 96
DON'T KNOW 98
137. Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NO. __
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?
OBSERVED, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (SKIP TO 145)
NOT OBSERVED, NO PERMISSION TO SEE 4 (SKIP TO 145)
NOT OBSERVED OTHER REASON 5 (SKIP TO 145)
140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.
WATER IS NOT AVAILABLE 2
141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING.
RECORD OBSERVATION
ASH, MUD, SAND B
NONE Y
142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
144. OBSERVER MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION
CANE/PALM/TRUNKS 12
DIRT 13
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
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
IODATE PRESENT, 15 PPM OR HIGHER 2 (GO TO 146)
NO IODATE, 0 PPM 3
NO SALT IN HOUSEHOLD 4 (GO TO 146)
SALT NOT TESTED (SPECIFY REASON) 6 (GO TO 146)
145B. TESTING FOR PRESENCE OF POTASIUM IODIDE
IODATE PRESENT, 15 PPM OR HIGHER 2
NO IODATE, 0 PPM 3
NO SALT IN HOUSEHOLD 4
SALT NOT TESTED (SPECIFY REASON) 6
SELECTION OF WOMAN AND MAN FOR THE DOMESTIC VIOLENCE QUESTIONS (PAPER OPTION)
TO BE FILLED IIN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW _____
COMMENTS ON SPECIFIC QUESTIONS _____
ANY OTHER COMMENTS ______
SUPERVISOR'S OBSERVATIONS _____
EDITOR'S OBSERVATIONS ____