IDENTIFICATION:

PLACE NAME ____

NAME OF HOUSEHOLD HEAD ____

EA NUMBER ____

HOUSEHOLD NUMBER ____

LESOTHO ECOLOGICAL ZONE:

DISTRICT CODE* ____

URBAN/RURAL:

HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKER COLLECTION?

INTERVIEWER VISITS:

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT CODE**

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT CODE**

NEXT VISIT:
DATE____
TIME____

THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT CODE**

FINAL VISIT
DAY____
MONTH____
YEAR 2014
INT. NUMBER____
RESULT CODE**

TOTAL NUMBER OF VISITS____

**RESULT CODES:

TOTAL PERSONS IN HOUSEHOLD___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE____

LANGUAGE OF QUESTIONNAIRE: ENGLISH 2

LANGUAGE OF QUESTIONNAIRE: ENGLISH 2

LANGUAGE OF INTERVIEW

TRANSLATOR USED

SUPERVISOR
NAME____
DATE____

INTRODUCTION AND CONSENT

Hello. My name is ________________________. I am working with the Ministry of Health. We are conducting a survey about health all over Lesotho. 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 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: ________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

HOUSEHOLD SCHEDULE

1) LINE NUMBER:

2) USUAL RESIDENTS AND VISITORS:

Please give me the names of the persons who live in your household and guests of the household who stayed here last night, starting with the head of the household.

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, or somewhere else in Lesotho, or outside Lesotho?

6) Does (NAME) live in South Africa or some other country?

7) How long has (NAME) lived in (COUNTRY)?
IF LESS THAN 1 YEAR, RECORD '00'.
RECORD '98' FOR DON'T KNOW.

8) Did (NAME) stay here last night?

8A) Just to make sure that I have a complete listing: are there any other persons such as small children that we have not listed?

8B) Are there any other people who may not be members of your family, such as domestic servants, lodgers, or friends who usually live here?

8C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

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

IF AGE 15 OR OLDER:

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

ELIGIBILITY:

11) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 WHO ARE USUAL RESIDENTS (COL. 5-1) AND/OR WHO SLEPT IN HH LAST NIGHT (COL. 8-1)

IF HH IS SELECTED FOR MALE SURVEY AND BIOMARKER COLLECTIONS:

12) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 WHO ARE USUAL RESIDENTS (COL. 5-1) AND/OR WHO SLEPT IN HH LAST NIGHT (COL. 8-1)

13) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5 WHO ARE USUAL RESIDENTS (COL. 5-1) AND/OR WHO SLEPT IN HH LAST NIGHT (COL. 8-1)

IF AGE 0-17 YEARS:

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:

14) Is (NAME)'s natural mother alive?

15) 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'.

16) Is (NAME)'s natural father alive?

17) 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:

18) Has (NAME) ever attended school?

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

IF AGE 5-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

20) Did (NAME) attend school at any time during the 2014 school year?

21) During this/that school year, what level and grade [is/was] (NAME) attending? SEE CODES.

IF AGE 0-4 YEARS:

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

TICK HERE IF CONTINUATION SHEET USED___

HOUSEHOLD CHARACTERISTICS

101) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

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

103) Where is the water source located?

104) How long does it take to go there, get water, and come back?

105) Do you do anything to the water to make it safer to drink?

106) What do you usually do to make the water safer to drink?
Anything else? RECORD ALL MENTIONED.

107) What kind of toilet facility do members of your household usually use?

108) Do you share this toilet facility with other households?

109) How many households use this facility?

110) Does you household have:

a) Electricity that is connected?
b) A battery or generator for power?
c) A solar panel in working condition?
d) A radio in working condition?
e) A television in working condition?
f) A mobile telephone in working condition?
g) A non-mobile telephone in working condition?
h) A refrigerator in working condition?
i) A bed/mattress?
j) A computer?
k) Internet access?

111) What type of fuel does your household mainly use for cooking?

112) Is the cooking usually done in the house, in a separate building, or outdoors?

113) Do you have a separate room which is used as a kitchen?

114) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

115) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

116) MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.

117) How many rooms in this household are used for sleeping?

118) Does any member of this household own:

a) A watch?
b) A bicycle?
c) A motorcycle or motor scooter?
d) A scotch cart?
e) A car or truck?

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 this household own any livestock, herds, other farm animals, or poultry?

122) How many of the following animals does this household own?
IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'.

a) Cattle?
b) Milk cows?
c) Bulls?
d) Horses, donkeys, or mules?
e) Goats?
f) Sheep?
g) Ordinary free range chickens?
h) Improved chickens?
i) Ordinary pigs?
j) Improved pigs?
k) Rabbits?

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

124) What is the name of the nearest health facility that provides health services to this community?

125) How do you get from here to (HEALTH FACILITY NAME)?

126) How long does it take you to get from here to (HEALTH FACILITY NAME)?

127) Please show me where members of your household most often wash their hands.

128) OBSERVATION ONLY: SEE IF THERE IS WATER AT PLACE FOR HANDWASHING.

129) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

130) Can you please provide me with a teaspoon of cooking salt? I will conduct a test to determine the presence of iodine. Iodine prevents goiter.

ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.