IDENTIFICATION (1)

PLACE NAME

NAME OF HOUSEHOLD HEAD _____

CLUSTER NUMBER ____

HOUSEHOLD NUMBER ____

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

HOUSEHOLD SELECTED FOR DOMESTIC VIOLENCE MODULE?

INTERVIEWER VISITS 1, 2, 3

NEXT VISIT

FINAL VISIT

TOTAL NUMBER OF VISITS ____

*RESULT CODES:

COMPLETED 1
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT
AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER ____ (SPECIFY) 9

TOTAL PERSONS IN HOUSEHOLD ____

TOTAL ELIGIBLE WOMEN _____

TOTAL ELIGIBLE MEN ____

RESPONDENT LINE NUMBER TO HOUSEHOLD QUESTIONNAIRE ____

QUESTIONNAIRE LANGUAGE** ____ (CODE)

QUESTIONNAIRE LANGUAGE** ____ (LANGUAGE)

LANGUAGE OF INTERVIEW** ____

NATIVE LANGUAGE OF RESPONDENT** ___

TRANSLATOR USED

**LANGUAGE CODES

FRENCH 01
MALAGASY 02
LANGUAGE 03
LANGUAGE 04
LANGUAGE 05
LANGUAGE 06
SUPERVISOR

NAME ____
NUMBER ___

INTRODUCTION AND CONSENT

Hello. My name is ____________. I am working with the NATIONAL INSTITUTE OF STATISTICS (INSTAT). We are conducting a survey about health and other subjects all over MADAGASCAR. 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?

INTERVIEWER SIGNATURE ____
DATE ____

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 100)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

100) RECORD THE TIME.

HOUSEHOLD QUESTIONNAIRE

1) LINE NUMBER. 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20

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, SEX, RESIDENCE, AND AGE 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?

SEE CODES BELOW.

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

HEAD 01
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
NO RELATION 11
DON'T KNOW 98

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'.

8) IF 12 OR OLDER: MARITAL STATUS

What is (NAME)'s current marital status?

9) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL WOMEN 15-49

10) ELIGIBILITY: IF HOUSEHOLD SELECTED FOR MAN'S SURVEY:

CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

11) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

IF 0-17 YEARS: SURVIVAL STATUS 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 (NAME) completed at that level?

SEE CODES BELOW.

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

18) Did (NAME) attend school or an early childhood education program at any time during the [2020-2021] school year?

19) During this (last) school year [2020-2021], what level and grade is/was (NAME) attending?

SEE CODES BELOW.

PAST SCHOOL ATTENDANCE

CODES FOR Qs. 17 AND 19: LEVEL OF EDUCATION

LEVEL

EARLY CHILDHOOD EDUCATION PROGRAM 0
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8

GRADE

LESS THAN ONE YEAR COMPLETED 00 (USE '00' FOR Q. 17 ONLY. THIS CODE IS NOT AUTHORIZED FOR Q. 19)

PRIMARY:

T1/CP1 OR 1ST YEAR 01
T2/CP2 OR 2ND YEAR 02
T3/CE OR 3RD YEAR 03
T4/CM1 OR 4TH YEAR 04
T5/CM2 OR 5TH YEAR 05
DON'T KNOW 98

SECONDARY 1:

T6/6ÈME OR 1ST YEAR 01
T7/5ÈME OR 2ND YEAR 02
T8/4ÈME OR 3RD YEAR 03
T9/3ÈME OR 4TH YEAR 04
DON'T KNOW 98

SECONDARY 2:

T10/2NDE OR 1ST YEAR 01
T11/1ÈRE OR 2ND YEAR 02
T12/TLE OR 3RD YEAR 03
DON'T KNOW 98

HIGHER:

1ST YEAR 01
2ND YEAR 02
3RD YEAR 03
4TH YEAR 04
5TH YEAR 05
DON'T KNOW 98

20) IF AGE 0-4: BIRTH REGISTRATION:

Does (NAME) have a birth certificate?

IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

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 the water source located?

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

104A) Who usually goes to the water source to get water for the household?

106) In the last month, has there been any time when your household did not have sufficient quantities of drinking water when needed?

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

108) What do you usually do to the water to make it safer to drink?

Anything else?

RECORD ALL MENTIONED

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

IF IT IS NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

110) Do you share this toilet facility with any other households?

111) Including your own household, how many households use this toilet facility?

112) Where is that toilet facility located?

113) In your household, what type of cookstove is mainly used 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:

a) Electricity?
b) A radio?
c) A television?
d) A non-mobile telephone?
e) A computer?
f) A refrigerator?
g) A bed?
h) A table?
i) A chair?
j) An armchair/sofa?
k) A sewing machine?
l) A fan?
m) A DVD/DIVX player?
n) A water heater?

122) Does any member of this household own:

a) A 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?

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?

127) Does your household have any mosquito nets?

128) How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

MOSQUITO NET #1, MOSQUITO NET #2, MOSQUITO NET #3

129) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF 3 OR MORE MOSQUITO NETS, USE ADDITIONAL QUESTIONNAIRE(S).

129A) OBSERVE OR ASK THE COLOR OF THE MOSQUITO NET

129B) OBSERVE OR ASK TO SEE THE SHAPE OF THE MOSQUITO NET

130) How many months ago did you 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 TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)

132) In the last 12 months, has the mosquito net been washed?

133) What was used to wash the mosquito net?

133A) How was the mosquito net dried?

134)Did you get the net through a local mass distribution campaign, during an antenatal care visit, from a community field worker, or during an immunization visit?

135) Where did you get the net?

136) Did anyone sleep under this mosquito net last night?

137) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.

137AA) GO BACK TO 129 FOR NEXT MOSQUITO NET; IF THERE ARE NO MORE NETS, GO TO Q.138A.

137AB) What was the main reason this net was not used last night?

138) GO BACK TO 139 FOR NEXT NET; OR, IF NO MORE NETS, GO TO Q.138A.

138A) Was any mosquito net in this household used for anything other than sleeping?

138B) What was it used for?

Anything else?

RECORD ALL MENTIONED.

OTHER HOUSEHOLD CHARACTERISTICS

139) We would like to learn 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.

151) 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) RECORD THE TIME.

TABLE TO SELECT WOMEN TO PARTICIPATE IN DOMESTIC VIOLENCE MODULE (PAPER OPTION)

CHECK THE LAST DIGIT OF THE HOUSEHOLD 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. FIND THE BOX WHERE THE ROW AND COLUMN MEET AND CIRCLE THE NUMBER IN THE BOX. THIS IS THE RANK NUMBER OF THE WOMAN SELECTED TO PARTICIPATE IN THE DOMESTIC VIOLENCE MODULE FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. RECORD THE NAME AND LINE NUMBER OF THE WOMAN SELECTED IN THE SPACE BELOW.

EXAMPLE: THE HOUSEHOLD NUMBER IS '716' AND COLUMN 9 OF THE HOUSEHOLD SCHEDULE SHOWS THREE ELIGIBLE WOMEN AGED 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN, GO TO COLUMN '3'. FIND THE BOX WHERE THE ROW AND COLUMN MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE TO FIND THE SECOND WOMAN ELIGIBLE FOR THE INTERVIEW (LINE NO. 4 IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE SPACE PROVIDED UNDER THE TABLE.

(LAST DIGIT OF HOUSEHOLD NUMBER, TOTAL NUMBER OF ELIGIBLE WOMEN IN HOUSEHOLD AGED 15-49) = VALUE

(0,1) = 1
(0, 2) = 2
(0, 3) = 2
(0, 4) = 4
(0, 5) = 3
(0, 6) = 6
(0, 7) = 5
(0, 8+) = 4

(1,1) = 1
(1, 2) = 1
(1, 3) = 3
(1, 4) = 1
(1, 5) = 4
(1, 6) = 1
(1, 7) = 6
(1, 8+) = 5

(2,1) = 1
(2, 2) = 2
(2, 3) = 1
(2, 4) = 2
(2, 5) = 5
(2, 6) = 2
(2, 7) = 7
(2, 8+) = 6

(3,1) = 1
(3, 2) = 1
(3, 3) = 2
(3, 4) = 3
(3, 5) = 1
(3, 6) = 3
(3, 7) = 1
(3, 8+) = 7

(4,1) = 1
(4, 2) = 2
(4, 3) = 3
(4, 4) = 4
(4, 5) = 2
(4, 6) = 4
(4, 7) = 2
(4, 8+) = 8

(5,1) = 1
(5, 2) = 1
(5, 3) = 1
(5, 4) = 1
(5, 5) = 3
(5, 6) = 5
(5, 7) = 3
(5, 8+) = 1

(6,1) = 1
(6, 2) = 2
(6, 3) = 2
(6, 4) = 2
(6, 5) = 4
(6, 6) = 6
(6, 7) = 4
(6, 8+) = 2

(7,1) = 1
(7, 2) = 1
(7, 3) = 3
(7, 4) = 3
(7, 5) = 5
(7, 6) = 1
(7, 7) = 5
(7, 8) = 3

(8,1) = 1
(8, 2) = 2
(8, 3) = 1
(8, 4) = 4
(8, 5) = 1
(8, 6) = 2
(8, 7) = 6
(8, 8+) = 4

(9,1) = 1
(9, 2) = 1
(9, 3) = 2
(9, 4) = 1
(9, 5) = 2
(9, 6) = 3
(9, 7) = 7
(9, 8+) = 5

160)

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW ____

COMMENTS ON SPECIFIC QUESTIONS ____

OTHER COMMENTS ____

SUPERVISOR'S OBSERVATIONS ___