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PAKISTAN DEMOGRAPHIC AND HEALTH SURVEY 2017-2018
HOUSEHOLD QUESTIONNAIRE

PAKISTAN
NATIONAL INSTITUTE OF POPULATION STUDIES

IDENTIFICATION

PROVINCE/REGION

PUNJAB 1
SINDH 2
KPK 3
BALOCHISTAN 4
GB 5
ICT 6
AJK 7
FATA 8

DISTRICT ______

TEHSIL ________

NAME OF HOUSEHOLD HEAD _______

CLUSTER NUMBER _______

HOUSEHOLD NUMBER _______

HOUSEHOLD SELECTED FOR MAN'S SURVEY?

YES 1
NO 2

HOUSEHOLD SELECTED FOR DV?

YES 1
NO 2

INTERVIEWER VISITS

FIRST VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______

SECOND VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______

THIRD VISIT
DATE _______
INTERVIWER'S NAME _______
RESULT* ______
NEXT VISIT DATE _____
TIME ______

FINAL VISIT
DAY _____
MONTH ______
YEAR _____
INT. NO. _______
RESULT* _______

TOTAL NUMBER OF VISITS _________

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN ______
TOTAL ELIGIBLE MEN _______
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _______

*RESULT CODES:

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) __________

LANGUAGE OF QUESTIONNAIRE** 01

LANGUAGE OF INTERVIEW** ________

NATIVE LANGUAGE OF RESPONDENT** _________

TRANSLATOR USED

YES 1
NO 2

LANGUAGE OF QUESTIONNAIRE ** ENLGISH

**LANGUAGE CODES

01 ENGLISH
02 URDU
03 SINDHI
04 PUNJABI
05 SARAIKI
06 BALUCHI
07 PUSHTO
08 OTHER

SUPERVISOR
NAME _____
NUMBER ______

FIELD EDITOR
NAME ______
NUMBER _______

KEYED BY
NUMBER _______

INTRODUCTION AND CONSENT:

Asalum-o-Alaikum. My name is _________. I am working with the National Institute of Population Studies. We are conducting a survey about health and other topics all over Pakistan. 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 30 to 35 minutes. All of the answers you give will be confidential and will not be shared with anyone other than the members of our survey teams. 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?

SIGNATURE OF INTERVIEWER _____________
DATE __________

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

RECORD THE TIME
HOURS _______
MINUTES _______

HOUSEHOLD SCHEDULE

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 5-34 FOR EACH PERSON.

3) RELATIONSHIP TO THE HEAD OF THE HOUSEHOLD

What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.

CODES FOR Q.3:

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
BROTHER/SISTER-IN-LAW 09
NIECE/NEPHEW 10
GRANDPARENTS 11
AUNT/UNCLE 12
OTHER RELATIVE 13
ADOPTED/STEPCHILD 14
NOT RELATED 15
DOMESTIC SERVANT 16
DON'T KNOW 98

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

MALE 1
FEMALE 2

RESIDENCE

5) Does (NAME) usually live here?

YES 1
NO 2

6) Did (NAME) stay here last night?

YES 1
NO 2

7) AGE: How old is (NAME)? IF LESS THAN 1 YEAR, WRITE '00.' IF 95 OR MORE, RECORD '95.'

IN YEARS ______

8) MARITAL STATUS (IF AGE 15 OR OLDER)

What is (NAME)'s current marital status?

MARRIED 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED 4

ELIGIBILITY
9) CIRCLE LINE NUMBER OF ALL WOMEN 15-49 WHO ARE MARRIED, DIVORCED/SEPARATED, OR WIDOWED

10) IF HOUSEHOLD SELECTED FOR MAN'S SURVEY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-49 WHO ARE MARRIED, DIVORCED/SEPARATED, OR WIDOWED.

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

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

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

YES 1
NO 2 (GO TO 14)
DON'T KNOW 8 (GO 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? RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'

LINE NO. ______

14) Is (NAME)'s natural father alive?

YES 1
NO 2 (GO TO 16)
DON'T KNOW 8 (GO TO 16)

15) Does (NAME)'s natural father usually live in this household or was he a guest last night? IF YES: What is his name? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'

LINE NO. ________

IF AGE 5 YEARS OR OLDER: EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20)

17) What is the highest class (NAME) has completed? SEE CODES BELOW.

00 LESS THAN CLASS 1 COMPLETED
01-10 CLASS 1-CLASS 10 (MATRIC)
11-12 CLASS 11-12
13-15 BACHELOR'S DEGREE
16 MASTER'S DEGREE OR MBBS, PhD, MPHIL, BSc (4 YEARS)
98 DON'T KNOW

IF AGE 5-24 YEARS: CURRENT/RECENT SCHOOL ATTENDANCE
18) Did (NAME) attend school at any time during this school year?

YES 1
NO 2 (GO TO 19A)

19) During [this/that] school year, what class/grade [is/was] (NAME) attending? SEE CODES BELOW.

CODES FOR Q.19:

00 LESS THAN CLASS 1 COMPLETED
01-10 CLASS 1-CLASS 10 (MATRIC)
11-12 CLASS 11-12
13-15 BACHELOR'S DEGREE
16 MASTER'S DEGREE OR MBBS, PhD, MPHIL, BSc (4 YEARS)
98 DON'T KNOW

19A) What is the main reason (NAME) is not attending school?

01 SCHOOL TOO FAR
02 TRANSPORT NOT AVAILABLE
03 FURTHER EDUCATION NOT NECESSARY
04 REQUIRED FOR HOUSEHOLD/FARM WORK
05 GOT MARRIED
06 COSTS TOO MUCH
07 NOT INTERESTED IN STUDIES
08 REPEATED FAILURES
09 DID NOT GET ADMISSION
10 NOT SAFE
11 NEED TO EARN
96 OTHER
98 DON'T KNOW

IF AGE 0-17 YEARS: REGISTRATION WITH NADRA
20) Does (NAME) have his/her name entered onto a 'bay' form?
IF YES: Does (NAME) have a birth certificate?
IF NO: Does (NAME) have a birth certificate?

1 NAME ON BAY FORM AND HAVE BIRTH CERTIFICATE
2 NAME ON BAY FORM AND HAVE NO BIRTH CERTIFICATE
3 ONLY BIRTH CERTIFICATE
4 NEITHER OF ABOVE
8 DON'T KNOW

20A) Does (NAME) have NIC card?

YES 1
NO 2

FOR ALL USUAL MEMBERS: IN-MIGRATION

21) Was (NAME) born in this village/city?

YES 1 (GO TO 25)
NO 2

21A) In which village/city was (NAME) born?
WRITE NAME OF PLACE.
IN THE FIRST BOX, WRITE CODE 1, 2, OR 3 AS FOLLOWS:

1 CITY (IF URBAN)
2 DISTRICT (IF RURAL)
3 OUTSIDE PAKISTAN
THEN, WRITE THE 3-DIGIT CODES AS PROVIDED. __________

22) From where did (NAME) move to this village/city the last time?
WRITE NAME OF PLACE.
IN THE FIRST BOX, WRITE CODE 1, 2, OR 3 AS FOLLOWS:

1 CITY (IF URBAN)
2 DISTRICT (IF RURAL)
3 OUTSIDE PAKISTAN
THEN, WRITE THE 3-DIGIT CODES AS PROVIDED. __________

23) In which year did (NAME) last move to this village/city?

_________

24) What was the primary reason for (NAME) to move to this village/city?

BETTER ECONOMIC OPPORTUNITY 1
MARRIAGE 2
ACCOMPANY FAMILY 3
STUDY 4
TRANSFERRED ON JOB 5
ESCAPE FROM VIOLENCE/NATURAL DISASTER 6
OTHER REASONS 7
DON'T KNOW 8

IF AGE 5 YEARS OR OLDER: SEEING DIFFICULTY

25) Does (NAME) wear glasses or contact lenses to help them see?

YES 1
NO 2 (GO TO 27)
DON'T KNOW 8 (GO TO 27)

26) I would like to know if (NAME) has difficulty seeing even when wearing glasses or contact lenses. Would you say that (NAME) has no difficulty seeing, some difficulty, a lot of difficulty, or cannot see at all?

NO DIFFICULTY SEEING 1 (GO TO 28)
SOME DIFFICULTY 2 (GO TO 28)
A LOT OF DIFFICULTY 3 (GO TO 28)
CANNOT SEE AT ALL 4 (GO TO 28)
DON'T KNOW 8 (GO TO 28)

27) I would like to know if (NAME) has difficulty seeing. Would you say that (NAME) has no difficulty seeing, some difficulty, a lot of difficulty, or cannot see at all?

NO DIFFICULTY SEEING 1
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8

HEARING DIFFICULTY

28) Does (NAME) wear a hearing aid?

YES 1
NO 2 (GO TO 30)
DON'T KNOW 8 (GO TO 30)

29) I would like to know if (NAME) has difficulty hearing even when using a hearing aid. Would you say that (NAME) has no difficulty hearing, some difficulty, a lot of difficulty, or cannot hear at all?

NO DIFFICULTY HEARING 1 (GO TO 31)
SOME DIFFICULTY 2 (GO TO 31)
A LOT OF DIFFICULTY 3 (GO TO 31)
CANNOT HEAR AT ALL 4 (GO TO 31)
DON'T KNOW 8 (GO TO 31)

30) I would like to know if (NAME) has difficulty hearing. Would you say that (NAME) has no difficulty hearing, some difficulty, a lot of difficulty, or cannot hear at all?

NO DIFFICULTY HEARING 1
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT HEAR AT ALL 4
DON'T KNOW 8

OTHER FUNCTIONAL DIFFICULTIES

31) I would like to know if (NAME) has difficulty communicating when using his/her usual language. Would you say that (NAME) has no difficulty understanding or being understood, some difficulty, a lot of difficulty, or cannot communicate at all?

NO DIFFICULTY COMMUNICATING 1
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT COMMUNICATE AT ALL 4
DON'T KNOW 8

32) I would like to know if (NAME) has difficulty remembering or concentrating. Would you say that (NAME) has no difficulty remembering or concentrating, some difficulty, a lot of difficulty, or cannot remember or concentrate at all?

NO DIFFICULTY REMEMBERING/CONCENTRATING 1
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT REMEMBER/CONCENTRATE AT ALL 4
DON'T KNOW 8

33) I would like to know if (NAME) has difficulty walking or climbing steps. Would you say that (NAME) has no difficulty walking or climbing steps, some difficulty, a lot of difficulty, or cannot walk or climb steps at all?

NO DIFFICULTY WALKING OR CLIMBING 1
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT WALK OR CLIMB AT ALL 4
DON'T KNOW 8

34) I would like to know if (NAME) has difficulty washing all over or dressing. Would you say that (NAME) has no difficulty washing all over or dressing, some difficulty, a lot of difficulty, or cannot wash all over or at all?

NO DIFFICULTY WASHING OR DRESSING 1
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT WASH OR DRESS AT ALL 4
DON'T KNOW 8

OUT MIGRATION

35) Now I would like to ask you about members of this household who lived here in the past 10 years but have since moved away. Are there any members of your household who lived here in the past 10 years but who have since moved away?

YES 1
NO 2 (GO TO 43)
DON'T KNOW 8 (GO TO 43)

36) MIGRANTS: Please give me the names of the persons who are living outside of this household?
AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP TO HOUSEHOLD HEAD AND SEX FOR EACH PERSON, ASK QUESTIONS 38-41A FOR EACH PERSON.

NAMES: __________

RELATION TO HOUSEHOLD HEAD
36A) What is the relationship of (NAME) to the head of the household?

HEAD 01
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
BROTHER/SISTER-IN-LAW 09
NIECE/NEPHEW 10
GRANDPARENTS 11
AUNT/UNCLE 12
OTHER RELATIVE 13
ADOPTED/STEPCHILD 14
NOT RELATED 15
DOMESTIC SERVANT 16
DON'T KNOW 98

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

MALE 1
FEMALE 2

38) MONTH AND YEAR MOVED AWAY: In what month and year did (NAME) move away?

MONTH ______
YEAR ________

39) AGE: How old was (NAME) when s/he moved away?
IF LESS THAN 1 YEAR, WRITE '00.' IF 95 OR MORE, RECORD '95.'

YEARS ________

IF AGE 5 YEARS OR OLDER:

39A) EDUCATION: What was the highest class (NAME) completed when he/she moved away?

CLASS ____

LESS THAN CLASS 1 COMPLETED 00
CLASS 1-CLASS 10 (MATRIC) 01-10
CLASS 11-12 11-12
BACHELOR'S DEGREE 13-15
MASTER'S DEGREE OR MBBS, PhD, MPHIL, BSc (4 YEARS) 16
DON'T KNOW 98

REASON FOR MIGRATION
40) What was the main reason that (NAME) moved away?

BETTER ECONOMIC OPPORTUNITY 1
MARRIAGE 2
ACCOMPANY FAMILY 3
STUDY 4
TRANSFERRED ON JOB 5
ESCAPE FROM VIOLENCE/NATURAL DISASTER 6
OTHER REASONS 7
DON'T KNOW 8

41) PLACE TRAVELLED TO: Where has (NAME) travelled to?
IF OTHER CITY OF PAKISTAN, ASK FOR NAME OF THE CITY AND CODE. IF OTHER PARTS OF PAKISTAN, ASK FOR NAME OF THE DISTRICT AND CODE. IF OUTSIDE PAKISTAN WRITE THE NAME OF THE COUNTRY AND PROVIDE THE CODE.

CITY IN PAKISTAN
NAME __________1
CODE_________
DISTRICT IN PAKISTAN
NAME ____________2
CODE _______
OUTSIDE PAKISTAN
NAME _________3
CODE__________
DON'T KNOW 9998

41A) REMITTANCE: In the past one year did you send money or receive money from (NAME)?

SEND MONEY 1
RECEIVED MONEY 2
NEITHER SEND NOR RECEIVED 3
DON'T KNOW 8

42) TOTAL NUMBER OF MIGRANTS _________
TICK IF CONTINUATION SHEET USED ___

SECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS

43) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR DV MODULE?

YES
NO (GO TO 101)

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL 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 QUESTIONNAIRE SERIAL 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 SERIAL 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.

44) NAME OF SELECTED WOMAN __________
HH LINE NUMBER OF SELECTED WOMAN ________

IF NO ELIGIBLE WOMAN IN THE HOUSEHOLD WRITE '00' AND SKIP TO 101.

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)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPER 14 (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 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 WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPER 14
TUBE WELL OR BOREHOLE 21

DUG WELL
PROTECTED WELL 31
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51
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 105)
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3

104) How long does it take to go there, get water, and come back? IF WATER IS DELIVERED AT HOME, RECORD.

MINUTES ______
DON'T KNOW 998

105) CHECK 101 AND 102: CODE '14' OR '21'

YES
NO (GO TO 107)

106) In the past two weeks, was the water from this source not available for at least one full day?

YES 1
NO 2
DON'T KNOW 8

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

YES 1
NO 2 (GO TO 109)
DON'T KNOW 8 (GO TO 109)

108) What do you usually do to make the water safer to drink? Anything else? RECORD 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

OTHER (SPECIFY) _________ X
DON'T KNOW Z

109) What kind of toilet facility do members of your household usually use? IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

FLUSH OR POUR FLUSH TOILET
FLUSH TO PIPER 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 113)

OTHER (SPECIFY) _________ 96

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

YES 1
NO 2 (GO TO 112)

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

NO. OF HOUSEHOLDS IF LESS THAN 10 ______
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

112) Where is this toilet facility located?

IN OWN DWELLING 1
IN OWN YARD 2
ELSEWHERE 3

113) What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
LPG 02
NATURAL GAS 03
BIOGAS 04
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 116)
OTHER (SPECIFY) _________ 96

114) 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 116)
OUTDOORS 3 (GO TO 116)

OTHER (SPECIFY) _________ 6 (GO TO 116)

115) Do you have a separate room which is used as a kitchen?

YES 1
NO 2

116) How many rooms in this household are used for sleeping?

ROOMS _______

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

YES 1
NO 2 (GO TO 119)

118) How many of the following animals does this household own?
IF NONE, RECORD '00.' IF 95 OR MORE, RECORD '95.' IF UNKNOWN, RECORD '98.'

A) Cows or bulls?
_______
B) Other cattle (buffalo)?

_______
C) Horses, donkeys, or mules?
_______
D) Goats?
_______
E) Sheep?
_______
F) Camels?
_______
G) Chicken or other poultry?
_______

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

YES 1
NO 2 (GO TO 121)

120) How many acres or kanals of agricultural land do members of this household own?

LAND
ACRES _______
KANAL ____
DON'T KNOW 9998

121) Does your household have:

a) Electricity?
YES 1
NO 2
b) A radio?
YES 1
NO 2
c) A television?
YES 1
NO 2
d) A non-mobile telephone?
YES 1
NO 2
e) A refrigerator?
YES 1
NO 2
f) Almirah/cabinet?
YES 1
NO 2
g) Chair?
YES 1
NO 2
h) Room cooler?
YES 1
NO 2
i) Air conditioner?
YES 1
NO 2
j) Washing machine?
YES 1
NO 2
k) Water pump?
YES 1
NO 2
l) Bed?
YES 1
NO 2
m) Clock?
YES 1
NO 2
n) Sofa?
YES 1
NO 2
o) Camera?
YES 1
NO 2
p) Sewing machine?
YES 1
NO 2
q) Computer?
YES 1
NO 2
r) Internet connection?
YES 1
NO 2

122) Does any member of this household own:

a) A watch?
YES 1
NO 2
b) A mobile phone?
YES 1
NO 2
c) A bicycle?
YES 1
NO 2
d) A motorcycle or motor scooter?
YES 1
NO 2
e) An animal-drawn cart?
YES 1
NO 2
f) A car or truck or bus?
YES 1
NO 2
g) A tractor?
YES 1
NO 2
h) A boat with a motor?
YES 1
NO 2
i) A boat without a motor?
YES 1
NO 2
j) A Rickshaw/chingchi?
YES 1
NO 2

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

YES 1
NO 2

124) How often does anyone smoke cigarette/huqa/berri or pipe inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?

DAILY 1
WEEKLY 2
MONTHLY 3
LESS OFTEN THAN ONCE A MONTH 4
NEVER 5

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

YES 1
NO 2 (GO TO 127)
DON'T KNOW 8 (GO TO 127)

126) Who sprayed the dwelling?

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C

OTHER (SPECIFY) ______ X
DON'T KNOW Z

127) Does your household have any mosquito nets?

YES 1
NO 2 (GO TO 139)

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 ALL 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 family get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00.'

MONTHS AGO _______
MORE THAN 36 MONTHS AGO 95
NOT SURE 98

131) OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET. IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
DAWA PLUS 11
YORKOOL 12
TANA NETTING 13
OTHER/DON'T KNOW BRAND 16
OTHER TYPE 96
DON'T KNOW TYPE 98

134) Did you get the net through Continuous LLINs Distribution (CD) Program, during an antenatal care visit, or during an immunization visit?

YES, CONTINUOUS LLINS DISTRIBUTION PROGRAM 1 (GO TO 136)
YES, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4

135) Where did you get the net?

GOV'T HEALTH FACILITY 01
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
SCHOOL 07
OTHER 96
DON'T KNOW 98

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

YES 1
NO 2 (GO TO 138)
NOT SURE 8 (GO TO 138)

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

NAME _______
LINE NO. _______

138) GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139

ADDITIONAL HOUSEHOLD CHARACTERISTICS

139) We would like to learn about the places that households use to wash their hands. Can you please show me where members of your household most often wash their hands?

OBSERVED, FIXED PLACE 1
OBSERVED, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (GO TO 142)
NOT OBSERVED, NO PERMISSION TO SEE 4 (GO TO 142)
NOT OBSERVED, OTHER REASON 5 (GO TO 142)

140) OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.

WATER IS AVAILABLE 1
WATER IS NOT AVAILABLE 2

141) OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.

SOAP OR DETERGENT (BAR, LIQUID, POWDER, PASTE) A
ASH, MUD, SAND B
NONE Y

142) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.

NATURAL FLOOR
EARTH/SAND 11
DUNG 12
RUDIMENTARY FLOOR
WOOD PLANK 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
CHIPS/TERRAZZO 36
BRICKS 37
MATS 38
MARBLE 39
OTHER (SPECIFY) _______ 96

143) OBSERVE THE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
SOD/GRASS 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANK 23
CARDBOARD 24
FINISHED ROOFING
ASBESTOS 31
REINFORCED BRICK CEMENT 32
METAL 33
WOOD 34
CALAMINE/CEMENT FIBER 35
CERAMIC TILES 36
CEMENT/RCC 37
ROOFING SHINGLE 38
OTHER (SPECIFY) __________ 96

144) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNKS 12
DIRT 13
MUD/STONES 14
BAMBOO/STICKS/MUD 15
RUDIMENTARY WALLS
UNBAKED BRICKS/MUD 21
BAMBOO WITH MUD 22
STONE WITH MUD 23
UNCOVERED ADOBE 24
PLYWOOD 25
REUSED WOOD 26
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) _______ 96

146) RECORD THE TIME

HOURS ______
MINUTES ________