ETHIOPIA

IDENTIFICATION

LOCALITY NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

HOUSEHOLD SELECTED FOR FEMALE GENITAL MUTILATION AND DOMESTIC VIOLENCE?

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S 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?

SUPERVISOR
NAME
NUMBER

FIELD EDITOR
NAME
NUMBER

OFFICE EDITOR
NUMBER

KEYED BY
NUMBER

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with Central Statistical Agency (CSA). We are conducting a survey about health and other topics all over Ethiopia. The information we collect will help the government to place 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 15-20 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 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?
May I begin the interview now?

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.

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. 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. CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF AGE 0-17: 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 5 YEARS OR OLDER: EVER ATTENDED SCHOOL

16. Has (NAME) ever attended school?

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

IF AGE 5-24 YEARS: CURRENT/RECENT SCHOOL ATTENDANCE

18. Did (NAME) attend school at any time during the (2015-2016) school year?

19. During (this/that) school year, what level and grade (is/was) (NAME) attending?

IF AGE 0-4 YEARS: BIRTH REGISTRATION

20. Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)'s birth ever been registered with the woreda or kebele?

HOUSEHOLD CHARACTERISTICS

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?

104A. Who usually goes to this source to fetch the water for your household?

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 king 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 cooing 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 ORE 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?

124. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?

ADDITIONAL HOUSEHOLD CHARACTERISTICS

139. We would like to learn about the places that household 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. OBSERVE 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 sample of the salt used to cook meals in your household?

TEST SALT FOR IODINE.

INJURIES/ACCIDENTS

146. In the last 12 months, was nay child or adult OF YOUR HOUSEHOLD killed or injured in any incident with injuries severe enough that for at least one day they could not carry out their normal activities?

147. What is the name of the person(s) injured or killed?

ENTER THE NAME OF EACH PERSON INJURED OR KILLED IN QUESTION 148.

IF THERE ARE MORE THAN TWO PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE.

148. NAME INJURED/KILLED

149. Could you tell me in what type of accident (NAME) was injured or killed?

150. Can you tell me the type of road accident (NAME) was injured or killed?

151. Is (NAME) still alive?

152. For how long did (NAME)'s injury prevent her/him from carrying out her/his normal daily activities?

153. IF ALIVE: RECORD LINE NUMBER FROM COLUMN (1).

RECORD '00' IF PERSON NOT LISTED IN HOUSEHOLD.

154. Was (NAME)'s death due to the accident?

155. Was (NAME) male or female?

156. How old was (NAME) when he/she died?

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

(TO BE ADDED TO THE HOUSEHOLD QUESTIONNAIRE)

CHECK COVER PAGE OF QUESTIONNAIRE: HOUSEHOLD SELECTED FOR FEMALE GENITAL MUTILATION MODULE (FGM) AND DOMESTIC VIOLENCE

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 01, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE)/ WRITE HER NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

157. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS

EDITOR'S OBSERVATIONS