NAME AND CODE OF REGION* ______________
NAME OF VILLAGE/TOWN/CITY ________________
URBAN/RURAL
RURAL 2
LARGE CITY/SMALL CITY/TOWN/RURAL
SMALL CITY 2
TOWN 3
RURAL 4
HOUSEHOLD NUMBER _____
NAME OF HOUSEHOLD HEAD _____________
IS HOUSEHOLD SELECTED FOR MAN'S SURVEY?
NO 2
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
NEXT VISIT: DATE ____ TIME ____
INTERVIEWER VISIT 2
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
NEXT VISIT: DATE ____ TIME ____
INTERVIEWER'S VISIT 3
DATE ______
INTERVIEWER'S NAME ______
RESULT** _____
FINAL VISIT
DAY ___
MONTH___
YEAR 200__
INT. NUMBER___
RESULT___
TOTAL PERSONS IN HOUSEHOLD___
TOTAL WOMEN 15-49___
TOTAL MEN 15-49___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___
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
DAMARA/NAMA 2
ENGLISH 3
HERERO 4
KWANGALI 5
LOZI 6
OSHIWAMBO 7
OTHER 8
RESPONDENT'S LANGUAGE:
DAMARA/NAMA 2
ENGLISH 3
HERERO 4
KWANGALI 5
LOZI 6
OSHIWAMBO 7
OTHER 8
LANGUAGE OF INTERVIEW:
DAMARA/NAMA 2
ENGLISH 3
HERERO 4
KWANGALI 5
LOZI 6
OSHIWAMBO 7
OTHER 8
TRANSLATOR USED
SOMETIMES 2
ALL THE TIME 3
FIELD EDITOR
NAME ___
DATE ___
OFFICE EDITOR ____
KEYED BY ___
CAPRIVI 01
ERONGO 02
HARDAP 03
KARAS 04
KHOMAS 05
KUNENE 06
CHANGWENA 07
KAVANGO 08
OMAHEKE 09
OMUSATI 10
OSHANA 11
OSHIKOTO 12
OTJOZONDJUPA 1
Hello. My name is _______________________________________ and I am working with the Ministry of Health and Social Services.
We are conducting a national survey about various health issues. We would very much appreciate your participation in this survey. The survey usually takes between 10 and 15 minutes to complete.
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 DOES NOT AGREE TO BE INTERVIEWED 2
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 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 5-32 FOR EACH PERSON.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
4) SEX: Is (NAME) male or female?
FEMALE 2
RESIDENCE
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
IF AGE 15 OR OLDER:
8) MARITAL STATUS: What is (NAME'S) current marital status?
DIVORCED/ SEPARATED 2
WIDOWED 3
NEVERMARRIED AND NEVER LIVED TOGETHER 4
ELIGIBILITY
9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-49
11) CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
CODES FOR Q. 3: RELATIONSHIP TO HEAD OF 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
NIECE/NEPHEW BY BLOOD 09
NIECE/NEPHEW BY MARRIAGE 10
OTHER RELATIVE 11
ADOPTED/FOSTER/STEPCHILD 12
NOT RELATED 13
DON'T KNOW 98
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?
NO 2
DK 8
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
13) Is (NAME)'s natural mother alive?
NO 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'.
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 activites?
NO 2
DK 8
16) Is (NAME)'s natural father alive?
NO 2 (GO TO 19)
DK 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'.
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?
NO 2
DK 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), CIRLCE '1'. FOR ALL OTHER CASES, CIRCLE '2'.
NO 2
BROTHERS AND SISTERS
21) Does (NAME) have any brothers or sisters under age 18 who have the same mother and the same father?
NO 2 (GO TO 23)
DK 8 (GO TO 23)
22) Do any of these brothers and sisters under age 18 not live in this household?
NO 2
IF AGE 5 YEARS OR OLDER OR OLDER
EVER ATTENDED SCHOOL
23) Has (NAME) ever attended school?
NO 2 (GO TO 29)
24) What is the highest level of school (NAME) has attended? SEE CODES BELOW. What is the highest grade (NAME) completed at that level? SEE CODES BELOW.
GRADE ___
CURRENT/RECENT SCHOOL ATTENDANCE
25) Did (NAME) attend school at any time during the (2006-2007) school year?
NO 2 (GO TO 27)
26) During this/that school year, what level and grade [is/was] (NAME) attending? SEE CODES BELOW.
GRADE ___
27) Did (NAME) attend school at any time during the previous school year, that is, (2005 2006)?
NO 2 (GO TO 29)
28) During that school year, what level and grade did (NAME) attend? SEE CODES BELOW.
GRADE ___
BASIC MATERIAL NEEDS
29) Does (NAME) have a blanket?
NO 2
DK 8
30) Does (NAME) have a pair of shoes?
NO 2
DK 8
31) Does (NAME) have at least two sets of clothes?
NO 2
DK 8
32) BIRTH REGISTRATION: Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever beenregistered with the civil authority?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
CODES FOR Qs. 24, 26, AND 28: EDUCATION
LEVEL
PRIMARY 1
SECONDARY 2
HIGHER 3
DON'T KNOW 8
GRADE
DON'T KNOW 98
101. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIPE 13 (GO TO 103)
DUG WELL
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
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 INTO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIPE 13
DUG WELL
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
OTHER (SPECIFY) ____ 96
103. Where is that water source located?
IN OWN YEARD/PLOT 2 (GO TO 106)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. Who usually goes to this source to fetch the water for your household?
ADULT MAN 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) ____ 6
106. Do you do anything to the water to make it safer to drink ?
NO 2 (GO TO 108)
DON'T KNOW 8 (GO TO 108
107. What do you usually do to make the water safe 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
OTHER (SPECIFY) ____ X
DON'T KNW Z
108. What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEHWERE 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 (GO TO 111)
OTHER (SPECIFY) ____ 96
109. Do you share this toilet facility with other households?
NO 2 (GO TO 111)
110. How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
111. Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
112. What type of fuel does your household mainly use for cooking?
LPG 02 (GO TO 115)
NATURAL GAS 03 (GO TO 115)
BIOGAS 04 (GO TO 115)
KEROSINE 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 on an open fire, an open stove or a closed stove?
CLOSED STOVE 2
CLOSED STOVE WITH CHIMNEY 3 (GO TO 115)
OTHE (SPECIFY) ____ 6 (GO TO 115)
114. Does this (fire/stove) have a chimney, a hood, or neither of these?
HOOD 2
NEITHER 3
115. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (GO TO 117)
OUTDOORS 3 (GO TO 117)
OTHER (SPECIFY) ____ (GO TO 117)
116. Do you have a separate room which is used as a kitchen?
NO 2
117. MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
118. MAIN MATERIAL ON THE ROOF. RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
119. MAIN MATERIAL OF THE EXTERIOR WALLS. RECORD OBSERVATION.
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 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
120. How many rooms in this household are used for sleeping?
121. Does any member of this household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
122. Does any member of this household own agricultural land?
NO 2 (GO TO 124)
123. How many hectares of agricultural land do members of this household own?
95 OR MORE HECTARES 95
DON'T KNOW 98
124 Does this household own any livestock, herds, other farm animals, or poultry?
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'.
COWS/BULLS ___
HORSES/DONKEY/MULES ___
GOATS ___
SHEEP ___
CHICKENS ___
126. Does any member of this household have a bank account?
NO 2
126A. What is the name of the nearest government health facility that provides health services to this community?
HEALTH CENTER 2
CLINIC 3
OUTREACH POINT 4
DON'T KNOW 6 (GO TO 126H)
FOR OFFICIAL USE ____
126B. If you were to go to (HEALTH FACILITY NAME), how would you go there?
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
OTHER (SPECIFY) ___ 5
126C. How long does it take from here to (HEALTH FACILITY NAME) by (MODE OF TRANSPORT IN 126B)?
HOURS 2 ___
DAYS 3 ___
126D. CHECK 126A: IS THE NEAREST FACILITY A HOSPITAL?
YES, A HOSPITAL __ (GO TO 126H)
126E. What is the name of the nearest government hospital that provides health services to this community?
FOR OFFICIAL USE ___
DON'T KNOW 8 (GO TO 126H)
126F. If you were to go to (NAME OF HOSPITAL, how would you go there?
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
OTHER (SPECIFY) ___ 6
126G. How long does it take from here to (NAME OF THE HOSPITAL) by (MODE OF TRANSPORT IN 126F)?
HOURS 2 ___
DAYS 3 ___
126H. In the last 12 months, has anyone in this household stayed overnight in a hospital or other health facility other than to deliver a baby?
NO 2
DON'T KNOW 8
127. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (GO TO 138)
128 How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
[Q. 129-Q. 137 ARE ASKED OF NET #1, NET #2 AND NET #3 SEPARATELY.]
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 obtain the mosquito net?
IF LESS THAN ONE MONTH RECORD '00'.
37 OR MORE MONTHS AGO 95
NOT SURE 98
131. OBSERVE OR ASK THE BRAND/TYPE OF NET.
YORKOOL 12 (GO TO 135)
SUPA NET PLUS 13 (GO TO 135)
OTHER/DK BRAND 16 (GO TO 135)
DK BRAND 98
132. When you got the net, was it treated with an insecticide to kill or repel mosquitos?
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?
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'.
25 OR MORE MONTHS AGO 95
NOT SURE 98
135. Did anyone sleep under this mosquito net last night?
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.
137. GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 138.
138. At any time in the past 12 months, has anyone sprayed the interior walls of your dwelling against mosquitoes?
NO 2 (GO TO 141)
DON'T KNOW 8 (GO TO 141)
139. How many months ago was the house sprayed? IF LESS THAN ONE MONTH, RECORD '00' MONTHS AGO.
PRIVATE COMPANY 2 (GO TO 142)
HOUSEHOLD MEMBER 3 (GO TO 142)
OTHER (SPECIFY) ____ 6 (GO TO 142)
DON'T KNOW 8 (GO TO 142)
141. What is the reason your house has not been sprayed?
DO NOT WANT SPRAYING 2
DO NOT NEED SPRAYING 3
OTHER (SPECIFY) ___ 6
DON'T KNOW ABOUT SPRAYING 7
DON'T KNOW 8
142. May I see a sample of the salt used for cooking last time?
BELOW 15 PPM 2
ABOVE 15 PPM (STRONG COLOUR) 3
NO SALT AT HOME 4 (GO TO 201)
NOT TESTED 5
REFUSED 6
143. What is the source of this salt: was it bought in a shop or from an open market or does it come from a salt pan?
OPEN MARKET 2
SALT PAN 3
OTHER 4
DON'T KNOW 8
201. CHECK QUESTIONS 7 AND 12 IN THE HOUSEHOLD SCHEDULE:
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.
[Q. 203-Q. 215 ARE ASKED OF 1ST SICK PERSON, 2ND PERSON AND 3RD PERSON SEPARATELY.]
203. NAME AND LINE NUMBER FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE.
LINE NO. ___
204. Now I would like to ask you about any support you received for (NAME). In the last
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?
NO 2 (GO TO 206)
DK 8 (GO TO 206)
205. Did your household receive any of this medical support at least once a month while (NAME) was sick?
NO 2
DK 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?
NO 2 (GO TO 208)
DK 8 (GO TO 208)
207. Did your household receive of this any emotional or psychological support in the past 30 days?
NO 2
DK 8
208. In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or finaincial support, for which you did not have to pay?
NO 2 (GO TO 210)
DK 8 (GO TO 210)
209. Did your household receive any of this material support in the past 30 days?
NO 2
DK 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 yoyu did not have to pay?
NO 2 (GO TO 212)
DK 8 (GO TO 212)
211. DId you household receive any of this social support in the past 30 days?
NO 2
DK 8
212. Now I would like to ask abou thealth problems (NAME) may have recently had. In the last 30 days, has (NAME) had sever pain, mild pain or no pain at all?
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?
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, 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?
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?
NO 2 (GO TO 401)
DK 8 (GO TO 401)
302. How many household members died in the 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)?
NAME 2ND DEATH ____
NAME 3RD DEATH ____
305. Was (NAME) male or female
FEMALE 2
306. How old was (NAME) when (he/she) died?
307. CHECK 306: AGE OF PERSON AT DEATH
18-59 (GO TO 308
308 Was (NAME) very sick for at least three of the 12 months before (he/she) died, that is was too sick to work or do normal activities?
NO 2 (GO TO 318)
DK 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?
NO 2 (GO TO 312)
DK 8 (GO TO 312)
311. Did your household receive any of this medical support at least once a month while (NAME) was sick?
NO 2
DK 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?
NO 2 (GO TO 314)
DK 8 (GO TO 314)
313. Did your household receive any of this emotional or psychological support in the last 30 days before (NAME)'s death?
NO 2
DK 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?
NO 2 (GO TO 316)
DK 8 (GO TO 316)
315. Did your household receive any of this material support in the last 30 days before (NAME)'s death?
NO 2
DK 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?
NO 2 (GO TO 318)
DK 8 (GO TO 318)
317. Did your household receive any of this social support in the last 30 days before (NAME)'s death?
NO 2
DK 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?
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?
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) sever?
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?
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?
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?
AT LEAST ONE SICK ADULT AGE 18-59 (GO TO 406. CHECK QUESTION 7 IN THE HOUSEHOULD 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?
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?
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.
[Q. 406- Q. 416 ARE ASKED OF 1ST CHILD, 2ND CHILD, 3RD CHILD AND 4TH CHILD SEPARATELY.]
406. NAME FROM COLUMN 2
LINE NUMBER FROM COLUMN 1
AGE FROM COLUMN 7
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.
NO 2 (GO TO 208)
DK 8 (GO TO 208)
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?
NO 2
DK 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?
NO 2 (GO TO 411)
DK 8 (GO TO 411)
410. Did your household receive any of this emotional or psychological support in the past 3 months?
NO 2
DK 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?
NO 2 (GO TO 413)
DK 8 (GO TO 413)
412. Did your household receive any of this material support in the past 3 months?
NO 2
DK 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?
NO 2 (GO TO 415)
DK 8 (GO TO 415)
414. Did your household receive any of this social support in the past 3 months?
NO 2
DK 8
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?
NO 2
DK 8
417. GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.
Q. 406-416 ARE ASKED OF 5TH CHILD, 6TH CHILD, 7TH CHILD AND 8TH CHILD SEPARATELY.
406. NAME FROM COLUMN 2
LINE NUMBER FROM COLUMN 1
AGE FROM COLUMN 7
LINE NO. ___
AGE ___
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?
NO 2
DK 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?
NO 2 (GO TO 411)
DK 8 (GO TO 411)
410. Did your household receive any emotional or psychological support in the past 3 months?
NO 2
DK 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?
NO 2 (GO TO 413)
DK 8 (GO TO 413)
412. Did your household receive any material support in the past months?
NO 2
DK 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?
NO 2 (GO TO 415)
DK 8 (GO TO 415)
414. Did your household receive any social support in the past 3 months?
NO 2
DK 8
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?
NO 2
DK 8
417. GO BACK TO 408 FOR NEXT CHILD; OR, IF NO MORE CHILDREN, GO TO 501.
WEIGHT AND HEIGHT MEASUREMENTS FOR CHILDREN AGED 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
[Q. 502-Q. 509 ARE ASKED OF CHILD 1, CHILD 2 AND CHILD 3 SEPARATELY.]
502. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
AGE FROM COLUMN 7
AGE ____
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?
MONTH ___
YEAR ___
504. CHECK 502 AND 503: CHILD AGE 0-5 OR BORN IN JANUARY 2001 OR LATER?
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 510)
507. MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
509. GO BACK TO 503 FOR NEXT CHILD IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); IF NO MORE CHILDREN, GO TO 510.
Q. 502-Q. 508 ARE ASKED OF CHILD 4, CHILD 5 AND CHILD 6 SEPARATELY.
502. LINE NUMBER FROM COLUMN 11
NAME FROM COLUMN 2
AGE FROM COLUMN 7
NAME ___
AGE ___
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?
MONTH ___
YEAR ___
504. CHECK 502 AND 503: CHILD AGE 0-5 OR BORN IN JANUARY 2001 OR LATER?
NO 2 (GO TO 503 FOR NEXT CHILD OR, IF NO MORE, GO TO 510)
507. MEASURED LYING DOWN OR STANDING UP?
STANDING UP 2
508. RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6
509. GO BACK TO 503 IN NEXT COLUMN IN THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF 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 MORE THAN SIX WOMEN, USE ADDITIONAL QUESTIONNAIRE(S). A FINAL OUTCOME MUST BE RECORDER FOR THE WEIGHT AND HEIGHT MEASUREMENT IN 514.
Q. 511- Q. 514 ARE ASKED OF WOMAN 1, WOMAN 2 AND WOMAN 3 SEPARATELY.
511. LINE NUMBER (COLUMN 9) ___
NAME (COLUMN 2) ___
514. RESULT OF WEIGHT AND HEIGHT MEASUREMENT
NOT PRESENT 2
REFUSED 3
OTHER 6