HOUSEHOLD QUESTIONNAIRE
PLACE NAME
NAME OF HEAD OF HOUSEHOLD
PLOT NUMBER
CLUSTER NUMBER
HOUSEHOLD NUMBER
Household selected for men's survey?
NO 2
INTERVIEWER'S NAME
FINAL VISIT
DAY
MONTH
YEAR 201
INT. NUMBER
RESULT
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
NEXT VISIT
DATE
TIME
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
LANGUAGE OF QUESTIONNAIRE: FRENCH 01
BAMBARA/MALINKE 02
SONRAI/DJERMA 03
PEUHL/FOULFOULDE 04
SENOUFO 05
MARKA/SONINKE 06
MINIANKA 08
TAMACHECK 09
BOBO/DAFING 10
BOZO/SOMONO 11
OTHER (SPECIFY) 96
BAMBARA/MALINKE 02
SONRAI/DJERMA 03
PEUHL/FOULFOULDE 04
SENOUFO 05
MARKA/SONINKE 06
MINIANKA 08
TAMACHECK 09
BOBO/DAFING 10
BOZO/SOMONO 11
OTHER (SPECIFY) 96
NO 2
SUPERVISOR
NAME
DATE
Hello. My name is ___. I am working with the National Institute of Statistics (INSTAT) and the Unit for Planning and Statistics (CPS). We are conducting a survey about health all over Mali. 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 DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES
1) LINE NO.
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.
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.
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 15-49
10) IF HOUSEHOLD SELECTED FOR MAN'S SURVEY
CIRCLE LINE NUMBER OF ALL MEN AGE 15-59
11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
Just to make sure that I have a complete listing:
2A) Are there any other persons such as small children or infants that we have not listed?
NO
2B) In addition, are there any other people who many 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
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
12) Is (NAME)'s natural mother alive?
NO 2 (SKIP TO 14)
DON'T KNOW 8 (SKIP 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? IF NO, RECORD 00.
14) Is (NAME)'s natural father alive?
NO 2 (SKIP TO 16)
DON'T KNOW 8 (SKIP TO 16)
15) Does (NAME)'s natural father live in this household or was he a guest last night?
IF YES, WHAT IS HIS NAME? IF NO, RECORD 00.
IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL
16) Has (NAME) ever attended school?
NO 2 (SKIP TO 30)
17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
GRADE _____
PRIMARY
LESS THAN 1 YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR 4
5TH YEAR 5
6TH YEAR 6
DON'T KNOW 8
SECOND CYCLE 2
8TH YEAR 2
9TH YEAR 3
DON'T KNOW 8
HIGH SCHOOL/TECHNICAL/PROFESSIONAL TRAINING
LESS THAN 1 YEAR 0
2ND YEAR/11TH YEAR 2
3RD YEAR/12TH YEAR 3
4TH YEAR 4
DON'T KNOW 8
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR 4
5TH YEAR 5
DON'T KNOW 8
IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during the (2015-2016) school year?
NO 2 (SKIP TO 30)
19) During this/that school year, what level and grade (is/was) (NAME) attending?
GRADE _____
PRIMARY
LESS THAN 1 YEAR 0
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR 4
5TH YEAR 5
6TH YEAR 6
DON'T KNOW 8
SECOND CYCLE 2
8TH YEAR 2
9TH YEAR 3
DON'T KNOW 8
HIGH SCHOOL/TECHNICAL/PROFESSIONAL TRAINING
LESS THAN 1 YEAR 0
2ND YEAR/11TH YEAR 2
3RD YEAR/12TH YEAR 3
4TH YEAR 4
DON'T KNOW 8
1ST YEAR 1
2ND YEAR 2
3RD YEAR 3
4TH YEAR 4
5TH YEAR 5
DON'T KNOW 8
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
DISABILITY
30) Does (NAME) wear glasses or contact lenses to see?
NO 2 (SKIP TO 32)
31) I'd like to know if (NAME) has trouble seeing even when he/she is wearing glasses or contact lenses. Would you say that (NAME) has no difficulty seeing, some difficulty, quite a bit of difficulty, or can't see at all?
SOME DIFFICULTY 2 (SKIP TO 36)
QUITE A BIT OF DIFFICULTY 3 (SKIP TO 36)
CAN'T SEE AT ALL 4 (SKIP TO 36)
DON'T KNOW 8 (SKIP TO 36)
32) I'd like to know if (NAME) has difficulty seeing. Would you say that (NAME) has no difficulty seeing, some difficulty, quite a bit of difficulty, or can't see at all?
SOME DIFFICULTY 2
QUITE A BIT OF DIFFICULTY 3
CAN'T SEE AT ALL 4
DON'T KNOW 8
36) Does (NAME) wear a hearing aid?
NO 2 (SKIP TO 35)
34) I'd like to know if (NAME) has difficulty hearing even when he/she is wearing a hearing aid. Would you say that (NAME) has no difficulty hearing, some difficulty, quite a bit of difficulty, or can't hear at all?
SOME DIFFICULTY 2 (SKIP TO 36)
QUITE A BIT OF DIFFICULTY 3 (SKIP TO 36)
CAN'T SEE AT ALL 4 (SKIP TO 36)
DON'T KNOW 8 (SKIP TO 36)
35) I'd like to know if (NAME) has difficulty hearing. Would you say that (NAME) has no difficulty hearing, some difficulty, quite a bit of difficulty, or can't hear at all?
SOME DIFFICULTY 2
QUITE A BIT OF DIFFICULTY 3
CAN'T HEAR AT ALL 4
DON'T KNOW 8
36) I'd like to know if (NAME) has difficulty communicating in his/her native language. Would you say that (NAME) has no difficulty understanding others or being understood by others, some difficulty, quite a bit of difficulty, or can't communicate at all?
SOME DIFFICULTY 2
QUITE A BIT OF DIFFICULTY 3
CAN'T COMMUNICATE AT ALL 4
DON'T KNOW 8
37) I'd like to know if (NAME) has difficulty remembering or focusing. Would you say that (NAME) has no difficulty remembering or focusing, some difficulty, quite a bit of difficulty, or can't remember or focus at all?
SOME DIFFICULTY 2
QUITE A BIT OF DIFFICULTY 3
CAN'T REMEMBER OR FOCUS AT ALL 4
DON'T KNOW 8
38) I'd like to know if (NAME) has difficulty bathing or dressing himself/herself. Would you say that (NAME) has no difficulty bathing or dressing, some difficulty, quite a bit of difficulty, or can't bathe or dress at all?
SOME DIFFICULTY 2
QUITE A BIT OF DIFFICULTY 3
CAN'T BATHE OR DRESS AT ALL 4
DON'T KNOW 8
101) What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (SKIP TO 106)
PIPED FROM NEIGHBOR 13 (SKIP TO 106)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
DUG WELL
UNPROTECTED WELL 32 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK/CANISTER OR INNER TUBE/BARRLE 71 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91
SACHET WATER 92
OTHER (SPECIFY) ___ 96 (SKIP TO 103)
102) What is the main source of water used by your household for other purposes such as cooking and handwashing?
PIPED INTO YARD/PLOT 12 (SKIP TO 106)
PIPED FROM NEIGHBOR 13 (SKIP TO 2016)
PUBLIC TAP/STANDPIPE 14
DUG WELL
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK/CANISTER OR INNTER TUBE/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER (SPECIFY) ___ 96 (SKIP TO 103)
103) Where is the water source located?
IN OWN YARD/PLOT 2 (SKIP TO 105)
ELSEWHERE 3
104) How long does it take you to go there, get water, and come back?
DON'T KNOW 998
105) CHECK 101 AND 102: CODE 14 OR 21 CIRCLED
NO (SKIP 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 (SKIP TO 109)
DON'T KNOW 8 (SKIP TO 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 A CLOTH C
USE WATER FILTER (CERAMIC/SAND/COMPOSITE/ETC.) D
SOLAR DISINFECTION E
LET IT STAND AND SETTLE F
ADD AQUATABS G
OTHER (SPECIFY) ___ X
DON'T KNOW Z
109) What kind of toilet facility do members of your household usually use?
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/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 113)
OTHER (SPECIFY) 96
110) Do you share this toilet facility with other households?
NO 2 (SKIP 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 mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KAROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95-SKIP 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 (SKIP TO 116)
OUTDOORS 3 (SKIP TO 116)
OTHER (SPECIFY) __ 6 (SKIP 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 (SKIP TO 119)
118) How many of the following animals does this household own?
IF NONE, ENTER 00
IF 95 OR MORE, ENTER 95
IF UNKNOWN, ENTER 98
119) Does any member of this household own any agricultural land?
NO 2 (SKIP TO 121)
120) How many hectares of agricultural land do members of this household own?
HECTARES
95 OR MORE H ECTARES 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
122) Does any member of your 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
124) Does anyone in your household smoke? Would you say daily, weekly, monthly, less than monthly, or never?
WEEKLY 2
MONTHLY 3
LESS THAN MONTHLY 4
NEVER 5
127) Does your household have any mosquito nets?
NO 2 (SKIP 139)
128) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD 7.
129) ASK THE RESPONDENT TO SHOW YOU 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.
RECORD THE NUMBER OF MONTHS
MORE THAN 37 MONTHS AGO 95
NOT SURE 98
131) OBSERVE OR ASK THE 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 11
PERMANET 12
INTERCEPTOR 13
SERENA 14
YORKOOL 15
OTHER/DON'T KNOW BRAND 16
OTHER TYPE 98
DON'T KNOW TYPE 98
134) Did you get the net through the mass distribution campaigns between 2015 and 2018, during an antenatal care visit, or during an immunization visit?
YES, CAMPAIGN OF 2106 2 (SKIP TO 136)
YES, CAMPAIGN OF 2017 3 (SKIP TO 136)
YES, CAMPAIGN OF 2018 4 (SKIP TO 136)
YES, ANC 5 (SKIP TO 136)
YES, IMMUNIZATION VISIT 6 (SKIP TO 136)
NO 7
135) Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
RELIGIOUS INSTITUTION 05
SCHOOL 06
NGO 07
ADMINISTRATIVE PERSONNEL 08
OTHER 96
DON'T KNOW 98
136) Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 138)
DK 8 (SKIP TO 138)
137) Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE
LINE NUMBER
138) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139.
139) We would like to learn about the places that households use to watch 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 142)
NOT OBSERVED, NO PERMISSION TO SEE 4 (SKIP TO 142)
NOT OBSERVED, OTHER REASON 5 (SKIP TO 142)
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 MATERIALS OF THE FLOOR IN THE DWELLING.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 36
CEMENT 34
CARPET 35
143) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 36
CEREAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
144) OBSERVE MAIN MATERIALS OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
BAMBOO/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 36
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?
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) 6
MINUTES
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT THE INTERVIEW:
COMMENTS ON SPECIFIC QUESTIONS:
ANY OTHER COMMENTS:
SUPERVISOR'S OBSERVATIONS