REPUBLIC OF CAMEROON
MINISTRY OF PUBLIC HEALTH
NATIONAL MALARIA PROGRAMME
2022 CAMEROON MALARIA INDICATOR SURVEY (2022 CMIS) HOUSEHOLD QUESTIONNAIRE
REGION
DIVISION
SUB-DIVISION
LACALITY
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
STRUCTURE NUMBER
HOUSEHOLD NUMBER
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT: DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
NEXT VISIT: DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT: DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR 2022
INT. NO.
RESULT*
TOTAL NUMBER OF VISITS
*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)
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF QUESTIONNAIRE** ENGLISH
LANGUAGE OF INTERVIEW**
NATIVE LANGUAGE OF RESPONDENT**
TRANSLATOR USED (YES = 1, NO = 2)
**LANGUAGE CODES:
01 ENGLISH
02 FRANCAIS
03 FUFULDE
04 PIDGIN
96 OTHER (SPECIFY)
TEAM
NUMBER
TEAM SUPERVISOR
NAME
NUMBER
Hello. My name is. I am working with he NATIONAL INSTITUTE OF STATISTICS. In collaboration with the MINISTRY OF PUBLIC HEALTH, we are conducting a survey about malaria all over Cameroon. The information we collect will help 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 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 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. GIVE CARD WITH CONTACT INFORMATION Do you have any questions? SIGNATURE OF INTERVIEWER DATE
RESPONDENT AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 END
MINUTES
01
02
03
04
05
06
07
08
09
10
USUAL RESIDENTS AND VISITORS
2
Please give me the names of the persons who usually live in your household an guests of the household who stayed here last night, starting with the head of the household. AFTER ASKING QUESTIONS 2-7 FOR EACH PERSON ASK QUESTIONS 7A-7C TO BE SURE THAT THE LISTING IS COMPLETE.
RELATIONSHIP TO HEAD OF HOUSEHOLD
3
What is the relationship of (NAME) to the head of the household? SEE CODES BELOW.
Is (NAME) male or female?
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
M 1
F 2
Does (NAME) usually live here?
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Did (NAME) stay here last night?
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
Y 1
N 2
How old is (NAME)? IF 95 OR MORE RECORD '95'.
IN YEARS
7A) 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?
YES (ADD TO TABLE)
NO
7B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?
YES (ADD TO TABLE)
NO
7C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
YES (ADD TO TABLE)
NO
CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD
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 REALTIVE
10 = ADOPTED/FOSTER/STEPCHILD
11 = NOT RELATED
12 = CO-WIFE
98 = DON'T KNOW
CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
01
02
03
04
05
06
07
08
09
10
9
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
01
02
03
04
05
06
07
08
09
10
101) What is the main source of drinking water for members of your household?
PIPED INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PIPED TO NEIGHBOR 13 (GO TO 105)
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
CACHET 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 INTO DWELLING 11 (GO TO 105)
PIPED TO YARD/PLOT 12 (GO TO 105)
PIPED TO NEIGHBOR 13 (GO TO 105)
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED SPRING 32
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANL/IRRIGATION CHANNEL) 81
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) 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 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 109)
OTHER (SPECIFY) 96
106) Do you share this toilet facility with other households?
NO 2 (GO TO 108)
107) Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
108) Where is this toilet facility with other households?
IN OWN YARD/PLOT 2
ELSEWHERE 3
109) In your household, what type of cookstove is mainly used for cooking?
SOLAR COOKER 02 (GO TO 111)
LIQUIFIED PETROLEUM GAS (LPG)/COOKING GAS STOVE 03 (GO TO 111)
PIPED NATURAL GAS STOVE 04 (GO TO 111)
BIOGAS STOVE 05 (GO TO 111)
LIQUID FUEL STOVE 06
MANUFACTURED SOLID FUEL STOVE 07
TRADITIONAL SOLID FUEL STOVE 08
THREE STONE STOVE/OPEN FIRE 09
NO FOOD COOKED IN HOUSEHOLD 95 111
OTHER (SPECIFY) 96
110) What type of fuel or energy source is used in the cookstove?
GASOLINE/DIESEL 02
KEROSENE/PARAFFIN 03
COAL/LIGNITE 04
CHARCOAL 05
WOOD 06
STRAW/SHRUBS/GRASS 07
AGRICULTRIAL CROP 08
ANIMAL DUNG/WASTE PROCESSED BIOMASS (PELLETS) OR WOODCHIPS 10
GARBADGE/PLASTIC 11
SAWDUST 12
OTHER (SPECIFY) 96
111) How many rooms in this household are used for sleeping?
113) How many of the following animals does this household own? IF NONE, RECORD '00'. IF 95 OR MORE, RECORD '95'. IF UNKNOWN, RECORD '98'. a) Milk cows or bulls? b) Other cattle? c) Horses, donkeys, or mules? d) Goats? e) Sheep? f) Pig? g) Chickens or other poultry?
b) OTHER CATTLE
c) HORSES/DONKEYS/MULES
d) GOATS
e) SHEEEP
f) PIG
g) CHICKENS/POULTRY
114) Does any member of this household own any agricultural land?
NO 2 (GO TO 116)
115) How many hectares of agricultural land do members of this household own? IF 95 OR MORE, CIRCLE '950'. 1 HECTARE = 10000m = 100mX100m
95 OR MORE HECTARES 950
DON'T KNOW 998
116) Does your household have: a) Electricity? b) A radio? c) A television? d) A non-mobile telephone? e) A desktop computer? f) A refrigerator/freezer? g) A cooker? h) A gas stove? I) An air conditioner? j) A fan? k) A CD/CVD player? l) A grain mill ou mixer? m) A modem/router unit safe for internet? n) A cable network/satellite dish? o) A generator? p) A solar panel? q) A water pump? r) A clock?
a) ELECTRICITY 1 2
b) RADIO 1 2
c) TELEVISION 1 2
d) NON-MOBILE TELEPHONE 1 2
e) DESKTOP COMPUTER 1 2
f) REFRIGERATOR/FREEZER 1 2
g) COOKER 1 2
h) GAS STOVE 1 2
i) AIR CONDITIONNER 1 2
j) FAN 1 2
k) CD/DVD PLAYER 1 2
l) GRAIN MILL/MIXER 1 2
m) MODEM/ROUTER 1 2
n) CABLE/SATELLITE DISH 1 2
o) GENERATOR 1 2
p) SOLAR PANEL 1 2
q) WATER PUMP 1 2
r) CLOCK 1 2
117) Does any member of this household own: a) A wrist watch? b) A mobile phone? c) A bicycle? d) A motorcycle or motor scooter? e) An animal -drawn cart? f) A car or truck? g) A boat with a motor? h) A laptop computer? i) A tablet computer?
a) WATCH 1 2
b) MOBILE PHONE 1 2
c) BICYCLE 1 2
d) MOTORCYCLE/SCOOTER 1 2
e) ANIMAL-DRAWN CART 1 2
f) CAR/TRUCK 1 2
g) BOAT WITH MOTOR 1 2
h) LAPTOP COMPUTER 1 2
i) TABLET COMPUTER 1 2
118) Does any member of this household have an account in a bank or other financial institution?
NO 2
119) Does any member of this household use a mobile phone to make financial transactions such as sending or receiving money, paying bills, purchasing goods or services, or receiving wages?
NO 2
120) Does your household have any mosquito nets?
NO 2 (GO TO 132)
121) How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. OBSERVE AND ANSWER THE QUESTIONS FOR EACH NET, ONE BY ONE.
122) ASSIGN EACH NET A SEQUENTIAL NUMBER AND RECORD THE NUMBER HERE
NET NUMBER
123) How many months ago did your household get this mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
125) OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
OLYSET NET 11
OLYSET PLUS 12
PERMANET 13
DURANET 14
YORKOOL 15
DAWA PLUS 16
INTERCEPTOR 17
ROYAL SENTRY 18
ROYAL GUARD 19
MAGNET 20
VEERALIN 21
YAHELLIN 22
SAFINET 23
PANDA-NET 24
OTHER/DON'T KNOW BRAND (LLIN) 26
OTHER TYPE (NOT LLIN) 96
DON'T KNOW TYPE 98
126) Did you get the net through the 2015-2016 distribution campaign (6-7 years ago), the 2019-2021 distribution campaign (1-3 years ago), this year (2022) distribution campaign, during an antenatal care visit, or during an immunization visit?
YES, 2019-2021 CAMPAIGN 2 (GO TO 128)
YES, 2022 CAMPAIGN 3 (GO TO 128)
YES, ANC 4 (GO TO 128)
YES, IMMUNIZATION VISIT 5 (GO TO 128)
NO 6
127) Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
COMMUNITY HEALTH WORKER 05
RELIGIOUS INSTITUTION 06
ASSICIATION/NGO 07
PARENT/FRIEND 08
OTHER 96
DON'T KNOW 98
128) Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 130)
NOT SURE (GO TO 131)
129) Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NUMBER (GO TO 131)
NAME
LINE NUMBER (GO TO 131)
NAME
LINE NUMBER (GO TO 131)
NAME
LINE NUMBER (GO TO 131)
130) What was the main reason this net was not used last night?
DON'T LIKE NET COLOR 02
DON'T LIKE NET MATERIAL/FABRIC 03
DON'T LIKE NET SIZE 04
DON'T LIKE SMELL 05
UNABLE TO HANG NET 06
SLEPT OUTDOORS 07
USUAL USER DIDN'T SLEEP HERE LAST NIGHT 08
NO MOSQUITOES/NO MALARIA 09
EXTRA NET/SAVING FOR LATER 10
OTHER (SPECIFY) 96
131) GO BACK TO 122 FOR NEXT NET; OR, IF NO MORE NETS, GO T0 132.
ADDITIONAL HOUSEHOLD CHARACTERISTICS
132) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.
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
133) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION.
NO ROOF 11
THATCH/PALM LEAF 12
SOD 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINSIHED ROOFING
METAL 31
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY) 96
134) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.
NO WALLS 11
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 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) 96
134a) OBSERVE THE COURTYARD AND IN THE VICINITY OF THE DWEILLING. ARE THERE PUDDLES OR POINTS OF STAGNANT OR ALMOST STAGNANT WATER WITHIN A RADIUS OF ABOUT 100 METERS FROM THE DWELLING OF THE HOUSEHOLD? LOOK FOR SWAMP, LAKE, LAGOON, RIVER, POND, UNCOVERED WLL, SPRING, AND WATER TRAPPED IN DISCARDED CANS, PLANT POTS, TIRES, DUG-OUTS, ROOFS, TREE TRUNKS ETC. RECORD OBERVATION.
NO BUSHES/TREES OBSERVED 2
134c) How long does it take in minutes to go from your home to the nearest public healthcare facility?
DON'T KNOW 998
134d) How long does it take in minutes to go from your home to the nearest private healthcare facility?
DON'T KNOW 998
MINUTES
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW:
COMMENTS ON SPECIFIC QUESTIONS:
ANY OTHER COMMENTS:
SUPERVISOR'S OBSERVATIONS