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NIGERIA DEMOGRAPHIC AND HEALTH SURVEY 2008
MODEL HOUSEHOLD QUESTIONNAIRE
WITH HIV/AIDS AND MALARIA MODULES

IDENTIFICATION

STATE ___________________ ___
LOCAL GOVT. AREA ________________ ___
LOCALITY ___________________ ___
ENUMERATION AREA _______________ ___

URBAN/RURAL:

URBAN l
RURAL 2

CLUSTER NUMBER __
BUILDING NUMBER __
HOUSEHOLD HEAD NAME/NUMBER ______________ ___

HOUSEHOLD SELECTED FOR MAN’S QUESTIONNAIRE:

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE __________
INTERVIEWER’S NAME ___________
RESULT* _____________

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) ___________

NEXT VISIT (FOR INTERVIEWERS 1 AND 2)
DATE __________
TIME ___________

FINAL VISIT
DAY ____
MONTH ____
YEAR 2008
INTERVIEWER NUMBER ____
RESULT _____

TOTAL NO. OF VISITS __

TOTAL PERSONS IN HOUSEHOLD __

TOTAL ELIGIBLE WOMEN__

TOTAL ELIGIBLE MEN __

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __

LANGUAGE OF INTERVIEW:

HAUSA 1
YORUBA 2
IGBO 3
ENGLISH 4
OTHER (SPECIFY) ___________ 6

NATIVE LANGUAGE OF RESPONDENT:

HAUSA 1
YORUBA 2
IGBO 3
ENGLISH 4
OTHER (SPECIFY) ___________ 6

TRANSLATOR USED?

YES 1
NO 2

SUPERVISOR
NAME ________ ___
DATE ________

FIELD EDITOR
NAME ________ ___
DATE ________

OFFICE EDITOR___

KEYED BY____

Introduction and Consent

Greetings. My name is _______________________________________ and I am working with National Population Commission. We are conducting a national survey that asks women and men about various health issues. This study has been reviewed and granted approval by the National Health Research Ethics Committee, assigned number NHREC/01/01/2007, for the study period of February 22, 2008 to February 23, 2009. We would very much appreciate your participation in this survey. This information will help the government to plan health services.
The survey usually takes between 20 and 30 minutes to complete. Whatever information you provide will be kept strictly confidential and will not be shown to other persons.
Should you have any queries, feel free to call any of the following contact person(s):

2008 NDHS Contact Person:
Project Director; Email: saligar58@yahoo.com; Phone: 08033708114

NHREC Contact Person(s):
Secretary, NHREC; Email: secretary@nhrec.net; Phone: 08033143791
Desk Officer, NHREC; Email: deskofficer@nhrec.net; Phone: 08065479926

As part of the survey we would first like to ask some questions about your household. All of the answers you give will be confidential. Participation in the survey is completely voluntary. If we should come to 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. However, we hope you will participate in the survey since your views are important.

At this time, do you want to ask me anything about the survey?
May I begin the interview now?

Signature of interviewer: ________________
Date: ________

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

HOUSEHOLD SCHEDULE

(1) LINE NO. (01-20)

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 5-38 FOR EACH PERSON.

NAME___________

(3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

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 BROTHER-IN-LAW/SISTER-IN-LAW
10 NIECE/NEPHEW BY BLOOD
11 NIECE/NEPHEW BY MARRIAGE
12 OTHER RELATIVE
13 ADOPTED/FOSTER/STEPCHILD
14 NOT RELATED
98 DON’T KNOW

(4) SEX: Is (NAME) male or female?

MALE 1
FEMALE 2

(5) RESIDENCE: Does (NAME) usually live here?

YES 1
NO 2

(6) RESIDENCE: Did (NAME) sleep here last night?

YES 1
NO 2

(7) AGE: How old was (NAME) as of last birthday?

IN YEARS __

(8) MARITAL STATUS IF AGE 15 OR OLDER: What is (NAME’S) current marital status?

1 MARRIED OR LIVING TOGETHER
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER MARRIED AND NEVER LIVED TOGETHER

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

(9A) ELIGIBILITY: CIRCLE LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE QUESTIONS IN Q.39.

(10) ELIGIBILITY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59 IF HH SELECTED FOR MALE INTERVIEW.

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

TICK HERE IF CONTINUATION SHEET USED. __

2A) Just to make sure that I have a complete listing. Are there any other persons such as small
children or infants that we have not listed?

YES (ADD TO TABLE)
NO

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?

YES (ADD TO TABLE)
NO

2C) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

YES (ADD TO TABLE)
NO

(12) SICK PERSON IF AGE 18-59 YEARS: Has (NAME) been very sick for at least 3 months during the past 12 months, that is (NAME) was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS IF AGE 0-17 YEARS:

(13) Is (NAME)’s natural mother alive?

Y 1
N 2 (GO TO 16)
DK 8 (GO TO 16)

(14) 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’.

LINE NUMBER_____

(15) IF MOTHER NOT LISTED IN HOUSEHOLD: Has (NAME)’s mother been very sick for at least 3 months during the past 12 months, that is she was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 19)
DON'T KNOW 8 (GO TO 19)

(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’.

LINE NUMBER_____

(18) IF FATHER NOT LISTED IN HOUSEHOLD: Has (NAME)’s father been very sick for at least 3 months during the past 12 months, that is he was too sick to work or do normal activities?

YES 1
NO 2
DON'T KNOW 8

(19) MOTHER AND/OR FATHER DEAD/ SICK: CIRCLE LINE NUMBER IF CHILD’S MOTHER AND/OR FATHER HAS DIED (Q.13 OR 16 NO) OR BEEN SICK (Q.15 OR 18 YES).

(20) BOTH PARENTS ALIVE: IF YES TO Q.13 AND Q.16 (BOTH ALIVE), CIRCLE ‘1’. FOR ALL OTHER CASES, CIRCLE ‘2’.

1 (GO TO 23)
2

BROTHERS AND SISTERS IF AGE 0-17 YEARS:

(21) Does (NAME) have any brothers or sisters age 0 - 17 who have the same mother and the same father?

YES 1
NO 2 (GO TO 23)
DON'T KNOW 8 (GO TO 23)

(22) Do any of these brothers and sisters age 0 - 17 not live in this household?

YES 1
NO 2

EVER ATTENDED SCHOOL IF AGE 5 YEARS OR OLDER:

(23) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 29)

(24) What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed at that level?
SEE CODES BELOW.
*FOR ‘HIGHER’, TOTAL THE NUMBER OF YEARS AT THE POST-SECONDARY LEVEL

LEVEL ___
0 PRE-PRIMARY/KINDERGARTEN
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON’T KNOW
CLASS/YEAR ___
01 - 03 YEARS AT PRE-PRIMARY/KINDERGARDEN LEVEL
01 - 06 YEARS 1 - 6 AT PRIMARY LEVEL
01 - 06 YEARS 1 - 6 AT SECONDARY LEVEL
01 - TOTAL NUMBER OF YEARS AT HIGHER LEVEL*
00 LESS THAN 1 YEAR COMPLETED (USE ‘00’ FOR Q. 24 ONLY. THIS CODE IS NOT ALLOWED FOR QS. 26 AND 28)
98 DON’T KNOW

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

(25) Did (NAME) attend school at any time during the (2007- 2008) school year?

YES 1
NO 2 (GO TO 27)

(26) During this school year, what level and grade is (NAME) attending?
SEE CODES BELOW.
*FOR ‘HIGHER’, TOTAL THE NUMBER OF YEARS AT THE POST-SECONDARY LEVEL

LEVEL ___
0 PRE-PRIMARY/KINDERGARTEN
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON’T KNOW
CLASS/YEAR ___

01 - 03 YEARS AT PRE-PRIMARY/KINDERGARDEN LEVEL
01 - 06 YEARS 1 - 6 AT PRIMARY LEVEL
01 - 06 YEARS 1 - 6 AT SECONDARY LEVEL
01 - TOTAL NUMBER OF YEARS AT HIGHER LEVEL*
00 LESS THAN 1 YEAR COMPLETED (USE ‘00’ FOR Q. 24 ONLY. THIS CODE IS NOT ALLOWED FOR QS. 26 AND 28)
98 DON’T KNOW

(27) Did (NAME) attend school at any time during the previous school year, that is, (2006-2007)?

YES 1
NO 2 (GO TO 29)

(28) During that school year, what level and grade did (NAME) attend?
SEE CODES BELOW.
*FOR ‘HIGHER’, TOTAL THE NUMBER OF YEARS AT THE POST-SECONDARY LEVEL

LEVEL ___
0 PRE-PRIMARY/KINDERGARTEN
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON’T KNOW
CLASS/YEAR ___
01 - 03 YEARS AT PRE-PRIMARY/KINDERGARDEN LEVEL
01 - 06 YEARS 1 - 6 AT PRIMARY LEVEL
01 - 06 YEARS 1 - 6 AT SECONDARY LEVEL
01 - TOTAL NUMBER OF YEARS AT HIGHER LEVEL*
00 LESS THAN 1 YEAR COMPLETED (USE ‘00’ FOR Q. 24 ONLY. THIS CODE IS NOT ALLOWED FOR QS. 26 AND 28)
98 DON’T KNOW

BASIC MATERIAL NEEDS IF AGE 5-17 YEARS

(29) Does (NAME) have a cover-cloth (blanket)?

YES 1
NO 2
DON'T KNOW 8

(30) Does (NAME) have a pair of shoes?

YES 1
NO 2
DON'T KNOW 8

(31) Does (NAME) have at least two sets of clothes?

YES 1
NO 2
DON'T KNOW 8

BIRTH REGISTRATION IF 0-4 YEARS:

(32) Was (NAME’S) birth registered?

YES 1
NO 2 (GO TO 34)
DON'T KNOW 8 (GO TO 34)

(33) With which authority was (NAME’S) birth registered?

1 NPOPC
2 LGA
3 PRIVATE CLINIC/HOSPITAL
4 OTHER

(33A) May I see (NAME’S) birth certificate?

1 SEEN
2 NOT SEEN

NEGLECTED TROPICAL DISEASES FOR ALL AGES:

(34) ONCHOCERIASIS: In the last 12 months, has (NAME) taken any drug for River Blindness [LOCAL TERM], a disease that causes itchy skin, lumps in the skin, and blindness?

YES 1
NO 2
DON'T KNOW 8

(35) LYMPHATIC FILARIASIS: In the last 12 months, has (NAME) taken any drug for elephantitis [LOCAL TERM], which causes swelling in the arms and legs?

YES 1
NO 2
DON'T KNOW 8

(36) GUINEA WORM: In the last 12 months, have you ever seen a worm emerging from a skin lesion (boil or blister) on (NAME)? This disease is called Guinea Worm.

YES 1
NO 2
DON'T KNOW 8

(37) SCHISTOSOMIASIS: In the last 12 months, has (NAME) taken any drug for bilharazia [LOCAL TERM], which causes blood in the urine?

YES 1
NO 2
DON'T KNOW 8

(38) SCHISTOSOMIASIS IN CHILDREN: Have you noticed any blood in (NAME’S) urine in the last month?

YES 1
NO 2
DON'T KNOW 8

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

39. LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS NUMBER IS USED TO IDENTIFY WHETHER THE FIRST (‘1’), SECOND (‘2’), THIRD (‘3’), ETC. ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
CIRCLE THE LINE NUMBER FOR THIS WOMAN IN COLUMN 9A.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS ‘36716’, GO TO ROW ‘6’.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN ‘3’.
FIND THE BOX WHERE ROW ‘6’ AND COLUMN ‘3’ MEET. THE NUMBER IN THAT BOX (‘2’) INDICATES THAT THE SECOND ELIGIBLE WOMAN IN THE HOUSEHOLD LISTING SHOULD BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE ‘02’, ‘03’, AND ‘07’. THE WOMAN TO BE ASKED THE DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE WOMAN ON LINE ‘03’.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN IN HOUSEHOLD (COLUMN)

HOUSEHOLD CHARACTERISTICS

101. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIPE 13 (GO TO 103)
TUBE WELL OR BOREHOLE 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 106)
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
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 WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIPE 13
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51 (GO TO 106)
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/ IRRIGATION CHANNEL) 81
OTHER (SPECIFY) __________ 96

103. Where is that water source located?

IN OWN DWELLING 1 (GO TO 106)
IN OWN YARD/PLOT 2 (GO TO 106)
ELSEWHERE 3

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

MINUTES _____
DON’T KNOW 998

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

ADULT WOMAN 1
ADULT WOMAN WITH CHILD 2
ADULT MAN 3
FEMALE CHILD UNDER 15 YEARS OLD 4
MALE CHILD UNDER 15 YEARS OLD 5
FEMALE AND MALE CHILD UNDER 15 YEARS OLD 6
ANY HOUSEHOLD MEMBER 7
OTHER (SPECIFY) _________8

106. Do you do anything to the water to make it safer to drink?

YES 1
NO 2 (GO TO 108)
DON’T KNOW 8 (GO TO 108)

107. What do you usually do to make the water safer to drink? Anything else?
CIRCLE ALL MENTIONED.

BOIL A
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
ALUM G
OTHER (SPECIFY) __________ X
DON’T KNOW Z

108. What kind of toilet facility do members of your household usually use?

FLUSH OR POUR FLUSH TOILET
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 111)
OTHER (SPECIFY) __________ 96

109. Do you share this toilet facility with other households?

YES 1
NO 2 (GO TO 111)

110. How many households use this toilet facility?

NUMBER OF HOUSEHOLDS IF LESS THAN 10 ___

10 OR MORE HOUSEHOLDS 95
DON’T KNOW 98

111. Does your household have the following items which are in good working order:

Electricity?
YES 1
NO 2
A radio?
YES 1
NO 2
A television?
YES 1
NO 2
A mobile telephone?
YES 1
NO 2
A non-mobile telephone?
YES 1
NO 2
A refrigerator?
YES 1
NO 2
A cable TV?
YES 1
NO 2
A generating set?
YES 1
NO 2
Air conditioner?
YES 1
NO 2
A computer?
YES 1
NO 2
Electric iron?
YES 1
NO 2
A fan?
YES 1
NO 2

112. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01 (GO TO 115)
LPG 02 (GO TO 115)
NATURAL GAS 03 (GO TO 115)
BIOGAS 04 (GO TO 115)
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 117)
OTHER (SPECIFY) ______________ 96

113. In this household, is food cooked mainly on an open fire, an open stove, or a closed stove?

OPEN FIRE 1
OPEN STOVE 2
CLOSED STOVE WITH CHIMNEY 3 (GO TO 115)
OTHER (SPECIFY) ___________ 6 (GO TO 115)

114. Does this (fire/stove) have a chimney, a hood, or neither of these?

CHIMNEY 1
HOOD 2
NEITHER 3

115. Is the cooking usually done in the house, in a separate building, or outdoors?

IN THE HOUSE 1
IN A SEPARATE BUILDING 2 (GO TO 117)
OUTDOORS 3 (GO TO 117)
OTHER (SPECIFY) _________ 6 (GO TO 117)

116. Do you have a separate room which is used as a kitchen?

YES 1
NO 2

117. MAIN MATERIAL FOR FINISH OF THE FLOOR.
RECORD OBSERVATION.

NATURAL FLOOR
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/RUG 35
OTHER (SPECIFY) ______ 96

118. MAIN MATERIAL FOR FINISH OF THE ROOF.
RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
METAL/ZINC 31
WOOD 32
CERAMIC TILES 33
CEMENT 34
ROOFING SHINGLES 35
OTHER (SPECIFY) ______ 96

119. MAIN MATERIAL FOR FINISH OF THE EXTERIOR WALLS.
RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT (MUD) 13
RUDIMENTARY WALLS
BAMBOO WITH MUD 21
STONE WITH MUD 22
PLYWOOD 23
CARDBOARD 24
REUSED WOOD 25
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
WOOD PLANKS/SHINGLES 35
OTHER (SPECIFY) ______ 96

120A. How many rooms in total are in your household, including rooms for sleeping and all other rooms?

ROOMS (TOTAL) ___

120B. How many rooms are used for sleeping in your household?

NUMBER OF ROOMS (SLEEPING) ___

121. Does any member of this household own:

A canoe?
YES 1
NO 2
A bicycle?
YES 1
NO 2
A motorcycle or motor scooter?
YES 1
NO 2
An animal-drawn cart?
YES 1
NO 2
A car or truck?
YES 1
NO 2
A boat with a motor?
YES 1
NO 2

122. Does any member of this household own any agricultural land?

YES 1
NO 2 (GO TO 124)

123. How much of agricultural land do members of this household own?

PLOT 1 __
ACRES 2 __
HECTARES 3 __

95 OR MORE PLOTS/ACRES/HECTARES 995
DON’T KNOW 998

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

YES 1
NO 2 (GO TO 126)

125. How many of the following animals does this household own?
IF NONE, ENTER ‘00’. IF MORE THAN 95, ENTER ‘95’. IF UNKNOWN, ENTER ‘98’.

Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens/Ducks?
Pigs?

Other (SPECIFY) _____________
Other (SPECIFY) _____________
COWS/BULLS __
HORSES/DONKEYS/MULES __
GOATS __
SHEEP __
CHICKENS/DUCKS __
PIGS __
OTHER __
OTHER __

126. Does any member of this household have a bank account?

YES 1
NO 2

127. Does your household have any mosquito nets that can be used while sleeping?

YES 1
NO 2 (GO TO 138)

128. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD ‘7’.

NUMBER OF NETS ___

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

OBSERVED 1
NOT OBSERVED 2

130. How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD ‘00’.

MONTHS AGO __

37 OR MORE MONTHS AGO 95
NOT SURE 98

131. Is this net an untreated net, a long-lasting net, or a re-treatable net?

UNTREATED NET 11 (GO TO 135)
LONG-LASTING NET 21 (GO TO 135)
RE-TREATABLE NET 31 (GO TO 133)
OTHER 41
DON’T KNOW 98

132. When you got the net, was it treated with an insecticide to kill or repel mosquitos?

YES 1
NO 2
NOT SURE 8

133. Since you got the mosquito net, was it ever soaked or dipped in a liquid to kill or repel mosquitos?

YES 1
NO 2 (GO TO 135)
NOT SURE 8 (GO TO 135)

134. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD ‘00’.

MONTHS AGO __

25 OR MORE MONTHS AGO 95
NOT SURE 98

135. Did anyone sleep under this mosquito net last night?

YES 1
NO 2 (GO TO 137)
NOT SURE 8 (GO TO 137)

136. Who slept under this mosquito net last night?
RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

NAME _____________
LINE NUMBER __

137. GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138.

138. ASK RESPONDENT FOR A TEASPOONFUL OF COOKING SALT.
TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION)

0 PPM (NO IODINE) 1
BELOW 15 PPM 2
15 PPM AND ABOVE 3
NO SALT IN HH 4
SALT NOT TESTED (SPECIFY REASON) ____________ 6

SUPPORT FOR SICK PEOPLE

201. CHECK QUESTIONS 7 AND 12 IN THE HOUSEHOLD SCHEDULE:
NUMBER OF SICK PEOPLE AGE 18-59

AT LEAST ONE (GO TO 202)
NONE (GO TO 301)

202. ENTER IN QUESTION 203 THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-59, BEGINNING WITH THE FIRST SICK PERSON LISTED IN QUESTION 12 IN THE HOUSEHOLD SCHEDULE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

READ THE INTRODUCTION THAT FOLLOWS. THEN ASK QUESTIONS 204-215 AS APPROPRIATE FOR EACH OF THE PERSONS AGE 18-59 REPORTED AS HAVING BEEN VERY SICK.

You told me that in your household one (some) of the members of your household has(ve) been very sick for at least three of the past 12 months. We are interested in learning about the care and support that may have been received for [that/each of those persons].
First I would like to ask you about any formal, organized help or support that your household may have been given for [that/ each of those] person(s) for which you did not have to pay.
By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

203. NAME AND LINE NUMBER FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE

NAME _____________
LINE NO. __

204. Now I would like to ask you about any support you received for (NAME).
In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

YES 1
NO 2 (GO TO 206)
DON'T KNOW 8 (GO TO 206)

205. Did your household receive any of these medical support at least once a month while (NAME) was sick?

YES 1
NO 2
DON'T KNOW 8

206. In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, for which you did not have to pay?

YES 1
NO 2 (GO TO 208)
DON'T KNOW 8 (GO TO 208)

207. Did your household receive any of these emotional or psychological support in the past 30 days?

YES 1
NO 2
DON'T KNOW 8

208. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

YES 1
NO 2 (GO TO 210)
DON'T KNOW 8 (GO TO 210)

209. Did your household receive any of these material support in the past 30 days?

YES 1
NO 2
DON'T KNOW 8

210. In the last 12 months, has your household received any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

YES 1
NO 2 (GO TO 212)
DON'T KNOW 8 (GO TO 212)

211. Did your household receive any of these social support in the past 30 days?

YES 1
NO 2
DON'T KNOW 8

212. Now I would like to ask about health problems (NAME) may have recently had.
In the last 30 days, has (NAME) had severe pain, mild pain, or no pain at all?

SEVERE 1
MILD 2
NOT AT ALL 3 (GO TO 214)

213. When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

214. In the last 30 days, did (NAME) suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Was this problem (were any of these problems) ever severe?

YES, SEVERE 1
YES, NEVER SEVERE 2
NO 3 (GO TO 216)

215. Was (NAME) able to reduce or stop this (these) problem(s) most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

216. GO BACK TO 204 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF THERE ARE NO MORE SICK PEOPLE, GO TO 301.

SUPPORT FOR PERSONS WHO HAVE DIED

301. Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has any usual member of your household died in the last 12 months?

YES 1
NO 2 (GO TO 401)
DON'T KNOW 8 (GO TO 401)

302. How many household members died in the last 12 months?

NUMBER OF DEATHS __

303. ASK 304-322 AS APPROPRIATE FOR EACH PERSON WHO DIED. IF THERE WERE MORE THAN 3 DEATHS, USE ADDITIONAL QUESTIONNAIRE(S).

304. What was the name of the person who died (most recently/before him/her)?

NAME ___________________

305. Was (NAME) male or female?

MALE 1
FEMALE 2

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

AGE _____

306A. Was the death of (NAME) registered with NPopC?

YES 1
NO 2
DON'T KNOW 8

307. CHECK 306:
AGE OF PERSON AT DEATH

LESS THAN 18/OVER 60 YEARS (GO TO 318)
18-59 (GO TO 308)

308. Was (NAME) very sick for at least three of the 12 months before (he/she) died, that is (NAME) was too sick to work or do normal activities?

YES 1
NO 2 (GO TO 318)
DON'T KNOW 8 (GO TO 318)

309. I would like to ask you about any formal, organized help or support that your household may have received for [NAME] before (he/she) died, for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

310. In the last 12 months, did your household receive any medical supplies for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

YES 1
NO 2 (GO TO 312)
DON'T KNOW 8 (GO TO 312)

311. Did your household receive any of these medical support at least once a month while (NAME) was sick?

YES 1
NO 2
DON'T KNOW 8

312. In the last 12 months, did your household receive any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor or spiritual support for which you did not have to pay?

YES 1
NO 2 (GO TO 314)
DON'T KNOW 8 (GO TO 314)

313. Did your household receive any of these emotional or psychological support in the last 30 days before (NAME)’s death?

YES 1
NO 2
DON'T KNOW 8

314. In the last 12 months, did your household receive any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

YES 1
NO 2 (GO TO 316)
DON'T KNOW 8 (GO TO 316)

315. Did your household receive any of these material support in the last 30 days before (NAME)’s death?

YES 1
NO 2
DON'T KNOW 8

316. In the last 12 months, did your household receive any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

YES 1
NO 2 (GO TO 318)
DON'T KNOW 8 (GO TO 318)

317. Did your household receive any of this social support in the last 30 days before (NAME)’s death?

YES 1
NO 2
DON'T KNOW 8

318. Now I would like to ask about the health problems (NAME) may have had.
In the 30 days before (NAME) died, did he/she have severe pain, mild pain, or no pain at all?

SEVERE 1
MILD 2
NOT AT ALL 3 (GO TO 320)

319. When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

320. In the 30 days before (NAME) died, did he/she suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Was this problem (were any of these problems) severe?

YES, SEVERE 1
YES, NEVER SEVERE 2
NO 3 (GO TO 322)

321. Was (NAME) able to reduce or stop the problems he/she had most of the time, some of the time or not at all?

MOST TIME 1
SOME TIME 2
NOT AT ALL 3

322. GO BACK TO 304 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF ADDITIONAL QUESTIONNAIRE(S); IF NO MORE DEATHS, GO TO 401.

SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

401. CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE:
ANY CHILD AGE 0-17?

AT LEAST ONE CHILD AGE 0-17 (GO TO 402)
NO CHILD AGE 0-17 (GO TO 501)

402. CHECK COLUMN 12 IN THE HOUSEHOLD SCHEDULE:
ANY SICK ADULT AGE 18-59 WHO IS VERY SICK?

NO SICK ADULT AGE 18-59 (GO TO 403)
AT LEAST ONE SICK ADULT AGE 18-59 (GO TO 406. CHECK QUESTION 7
IN THE HOUSEHOLD SCHEDULE AND LIST THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL PERSONS AGE 0-17 YEARS.)

403. CHECK 306 IN THE PREVIOUS SECTION:
ANY ADULT AGE 18-59 WHO DIED IN PAST 12 MONTHS?

NO ADULT DEATH AGE 18-59 IN 306 (GO TO 404)
AT LEAST ONE ADULT DEATH AGE 18-59 IN 306 (GO TO 406. CHECK QUESTION 7 IN THE HOUSEHOLD SCHEDULE AND LIST THE NAME(S), LINE NUMBER(S) AND AGE(S) OF ALL PERSONS AGE 0-17 YEARS.)

404. CHECK COLUMN 19 IN THE HOUSEHOLD SCHEDULE: ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND IS VERY SICK?

AT LEAST ONE CHILD WHOSE MOTHER AND/OR FATHER HAS DIED/IS NOT LISTED IN THE HOUSEHOLD SCHEDULE AND HAS BEEN VERY SICK (GO TO 405)
NO CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR IS NOT LISTED IN HOUSEHOLD SCHEDULE AND HAS BEEN VERY SICK (GO TO 501)

405. RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AGE 0-17 FOR ALL CHILDREN WHO ARE IDENTIFIED IN COLUMN 19 AS HAVING A MOTHER AND/OR FATHER WHO HAS DIED OR HAS BEEN VERY SICK.

406. NAME FROM COLUMN 2
LINE NUMBER FROM COLUMN 1
AGE FROM COLUMN 7

NAME ___________
LINE NO. ___
AGE ___

407. I would like to ask you about any formal, organized help or support for children that your household may have received for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

408. Now I would like to ask you about the support your household received for (NAME).
In the last 12 months, has your household received any medical support for (NAME), such as
medical care, supplies or medicine, for which you did not have to pay?

YES 1
NO 2
DON'T KNOW 8

409. In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support,
which you received at home and for which you did not have to pay?

YES 1
NO 2 (GO TO 411)
DON'T KNOW 8 (GO TO 411)

410. Did your household receive any of these emotional or psychological support in the past 3 months?

YES 1
NO 2
DON'T KNOW 8

411. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

YES 1
NO 2 (GO TO 413)
DON'T KNOW 8 (GO TO 413)

412. Did your household receive any of these material support in the past 3 months?

YES 1
NO 2
DON'T KNOW 8

413. In the last 12 months, has your household received any social support for (NAME) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

YES 1
NO 2 (GO TO 415)
DON'T KNOW 8 (GO TO 415)

414. Did your household receive any of this social support in the past 3 months?

YES 1
NO 2
DON'T KNOW 8

415. CHECK 406:
AGE OF CHILD

AGE 0-4 (GO TO 417)
AGE 5-17 (GO TO 416)

416. In the last 12 months, has your household received any support for (NAME’S) schooling, such as allowance, free admission, books or supplies, for which you did not have to pay?

YES 1
NO 2
DON'T KNOW 8

417. GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5

501. CHECK COLUMN 11. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 508.

502. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

LINE NO. ___
NAME ___________

503. IF MOTHER INTERVIEWED, COPY MONTH AND YEAR FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: What is (NAME’S) birth date?

DAY __
MONTH __
YEAR __

504. CHECK 503:
CHILD BORN IN JANUARY 2003 OR LATER?

YES 1
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 510)

505. WEIGHT IN KILOGRAMS

KG. ___.___

506. HEIGHT IN CENTIMETERS

CM. ___ .___

507. MEASURED LYING DOWN OR STANDING UP?

LYING DOWN 1
STANDING UP 2

508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

509. GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST
COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 510.

WEIGHT AND HEIGHT MEASUREMENT FOR WOMEN AGE 15-49

510. CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 511.
IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).
A FINAL OUTCOME MUST BE RECORDED FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 514.

511. LINE NUMBER (COLUMN 9)
NAME (COLUMN 2)

LINE NO. ___
NAME ___________

512. WEIGHT IN KILOGRAMS

KG. __.__

513. HEIGHT IN CENTIMETERS

CM. __.__

514. RESULT OF WEIGHT AND HEIGHT MEASUREMENT

MEASURED 1
NOT PRESENT 2
REFUSED 3
OTHER 6

25 June 2008
CONFIDENTIAL