NATIONAL POPULATION COMMISSION
National Health Research Ethics Committee
Assigned Number NHREC/01/01/2007

IDENTIFICATION

STATE ____
LOCAL GOVT. AREA ____
LOCALITY ____
ENUMERATION AREA ____

URBAN/RURAL

CLUSTER NUMBER ____
BUILDING/STRUCTURE NUMBER ____
HOUSEHOLD NUMBER ____

NAME OF HOUSEHOLD HEAD ____

HOUSEHOLD SELECTED FOR MAN'S QUESTIONNAIRE

INTERVIEWER VISITS

FIRST VISIT
DATE ____
INTERVIEWER NAME ____
RESULT*

NEXT VISIT:
DATE ____
TIME ____

SECOND VISIT
DATE ____
INTERVIEWER NAME ____
RESULT*

NEXT VISIT:
DATE ____
TIME ____

THIRD VISIT
DATE ____
INTERVIEWER NAME ____
RESULT*

FINAL VISIT
DAY ____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT*

TOTAL NUMBER OF VISITS ____

*RESULT CODES

TOTAL PERSONS IN HOUSEHOLD____

TOTAL ELIGIBLE WOMEN______

TOTAL ELIGIBLE______

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE______

LANGUAGE OF INTERVIEW

NATIVE LANGUAGE OF RESPONDENT

TRANSLATOR USED?

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 survey about health all over Nigeria. 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 the research team. You don't have to be in the survey, but we hope you will agree to answer the question 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 persons listed below:
2013 NDHS Contact Person: Project Director; Email: amakaloveth4life@yahoo.com; Phone: 08033318224
NHREC Contact Person: Desk Officer, NHREC; Email: yaminads@yahoo.com; Phone: 08065479926

Do you have any questions?
May I begin the interview now?

Signature of interviewer: ______________________ Date: ______________

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 slept 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 5-32 FOR EACH PERSON.

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?

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

7) 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

ELIGIBILITY:
9A) CIRCLE LINE NUMBER OF WOMAN SELECTED FOR DOMESTIC VIOLENCE QUESTIONS IN Q.33.

ELIGIBILITY:
10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49 IF HH SELECTED FOR MALE INTERVIEW

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

12) SICK PERSON: 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?

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

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

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."

IF MOTHER NOT LISTED IN HOUSEHOLD:

15) Has (NAME)'s mother been very sick for at least months during the past 12 months, that is she was too sick to work or do normal activities?

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 FATHER NOT LISTED IN HOUSEHOLD:

18) Has (NAME)'s father been very sick for at least 3 months during the 12 months, that is he was too sick to work or do normal activities?

MOTHER AND/OR FATHER DEAD/SICK:

19) 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)

BOTH PARENTS ALIVE:

20) IF YES TO Q. 13 AND Q. 16 (BOTH ALIVE), CIRCLE '1' (GO TO 23). FOR ALL OTHER CASES, CIRCLE '2'.

IF AGE 0-7 YEARS:

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

23) Do any of these brothers or sisters age 0-17 live elsewhere and not in this household?

IF AGE 5 YEARS OR OLDER:

23) EVER ATTENDED SCHOOL: Has (NAME) ever attended school?

24) What is the highest level of school (NAME) has attended
What is the highest class/year (NAME) completed at that level?

IF AGE 5-24 YEARS:

25) CURRENT/RECENT SCHOOL ATTENDANCE: Did (NAME) attend school at any time during the (2012-213) school year?

26) During this/that school year, what level and class/year is/was (NAME) attending?

BASIC MATERIAL NEEDS"

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

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

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

BIRTH REGISTRATION:

30) Was (NAME'S) birth registered?

31) With which authority was (NAME'S) birth registered?

32) May I see (NAME)'s birth certificate?

33. TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

LOOK AT 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. 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 NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 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 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.

HEADER FOR LEFT-HAND COLUMN: "LAST DIGIT OF THE HOUSEHOLD NUMBER" (VALUES 0-9 BELOW THIS)

HEADER FOR TOP ROW OF TABLE: "TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 9" (COLUMNS WITH 1'S, 2'S, 3'S, 4'S, 5'S, 6'S, 7'S, AND 8'S FILL THE CELLS OF THE TABLE.)

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 member of your household?

103) Where is that 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?
CIRCLE 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 toilet facility?

110) Does your household have:

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 us 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

117A) How many rooms in total are in your household, including rooms for sleeping and all other rooms?

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

118) Does any member of this household own:

119) Does any member of this household own any agricultural land?

120) How many plots/acres/hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '9950'

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

122) How many of the following animals does this household own?

Milk cows or bulls?
Horses, donkeys, or mules?
Goats?
Sheep?
Chickens/Ducks?
Pigs?
Other (SPECIFY) ____
Other (SPECIFY) ____

IF NONE, ENTER '00'. IF MORE THAN 95, ENTER '95'. IF UNKNOWN, ENTER '98'

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

124) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

125) Who sprayed the dwelling?

126) Does your household have any mosquito nets that can be used while sleeping?

127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'

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

129) How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'

130) 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.

131) When you got the net, was it already treated with an insecticide to kill or repel mosquitos?

132) Did anyone sleep under this mosquito net last night?
IF 'YES' CHECK 128 FOR CODE '2' CIRCLED THEN PROBE.

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

134) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 135.

135) Please show me where members of your household most often wash their hands?

136) OBSERVATION ONLY:
OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING.

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

SUPPORT FOR SICK PEOPLE

LEFT SIDE HEADER: QUESTIONS AND FILTERS
RIGHT SIDE HEADER: CODING CATEGORIES

201) CHECK QUESTIONS 7 AND 12 IN THE HOUSEHOLD SCHEDULE:

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 (have) 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

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?

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

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?

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

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 play.

209) Did your household receive any of these material support in the last 30 days?

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

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

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?

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

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?

215) Was (NAME) able to reduce or stop this (these) problems(s) by any means most of the time, some of time, or not all?

216) GO BACK TO 204 IN THE 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 PEOPLE WHO HAVE DIED

TOP LEFT HEADING: QUESTIONS AND FILTERS
TOP RIGHT HEADING: CODING CATEGORIES

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?

302) How many household members died in last 12 months?

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)?

305) Was (NAME) male or female?

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

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

307) CHECK 306:

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?

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?

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

312) In the last 12 months, did your household receive any emotional of psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did have to pay?

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

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?

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

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?

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

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?

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?

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?

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?

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?

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

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

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.

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

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?

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?

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

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?

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

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

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

415) CHECK 406: AGE OF CHILD

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?

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 YEARS

501) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 502. IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

502) LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2

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

504) CHECK 503: CHILD BORN IN JANUARY 2008 OR LATER?

505) WEIGHT IN KILOGRAMS

506) HEIGHT IN CENTIMETERS

507) MEASURED LYING DOWN OR STANDING UP?

508) GO BACK TO 503 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 510.

WEIGHT AND HEIGHT MEASUREMENT FOR WOMEN AGE 15-49 YEARS

510) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 511. IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

511) LINE NUMBER FROM COLUMN 9
NAME FROM COLUMN 2:

512) WEIGHT IN KILOGRAMS

513) HEIGHT IN CENTIMETERS

514) PREGNANCY STATUS: CHECK 226 IN WOMAN'S QUESTIONNAIRE OR ASK: Are you pregnant?

515) GO BACK TO 511 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END INTERVIEW.