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August 2015

2015-16 TANZANIA DEMOGRAPHIC AND HEALTH AND MALARIA INDICATOR SURVEY - HOUSEHOLD QUESTIONNAIRE

UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS

QST. No. ______

IDENTIFICATION

REGION _____

DISTRICT _____

WARD _____

LARGE CITY, MUNICIPALITY, SMALL TOWN, COUNTRISIDE (1)

LARGE CITY 1
MUNICIPALITY 2
SMALL TOWN 3
RURAL 4

NAME OF HOUSEHOLD HEAD _____

HOUSEHOLD NUMBER _____

HOUSEHOLD SELECTED FOR MAN’S SURVEY, SALT AND URINE TESTING?

YES 1
NO 2

(1) CITY: DSM, TANGA, MWANZA. MUNICIPALITY= DODOMA, KILIMANJARO, MOROGORO, PWANI, LINDI, MTWARA, SONGEA, IRINGA, SINGIDA, TABORA, RUKWA, SHINYANGA, KAGERA, MARA, MJIONI MAGHARIBI, WETE, CHAKE CHAKE, MKOANI. SMALL TOWN: ALL OTHER CITIES. RURAL: ALL OTHER AREAS.

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

DATE _____
INTERVIEWER’S NAME _____
RESULT*

*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) _____

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 _____

LANGUAGE OF QUESTIONNAIRE: 01
LANGUAGE OF QUESTIONNAIRE: ENGLISH
LANGUAGE OF INTERVIEW: _______

LANGUAGE CODES:

01 ENGLISH
02 KISWAHILI

TRANSLATOR USED

YES 1
NO 2

SUPERVISOR

NAME _____
NUMBER _____

FIELD EDITOR

NAME _____
NUMBER _____

OFFICE EDITOR

NUMBER _____

KEYED BY

NUMBER _____

INTRODUCTION AND CONSENT

Hello. My name is ____________________. I am working with the National Bureau of Statistics (NBS). We are conducting a survey about health and other topics all over the United Republic of Tanzania. 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 20 to 25 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. You don’t have to be in the survey, but we how you will agree to answer the questions since your views are important. If I ask you any question you don’t want to answer, just let me know and I will go on to the next question or you can stop the interview at any time. In case you need more information about the survey, you may contact the person listed on this card.

GIVE CARD WITH CONTACT INFORMATION

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

SIGNATURE OF INTERVIEWER __________________
DATE ______

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

100. RECORD THE TIME.

HOURS _____
MINUTES _____
MORNING 1
AFTERNOON 2
EVENING 3

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 COLUMN 5-25 FOR EACH PERSON.

2A. Just to make sure that I have a complete listing: are there any other people 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 stayed here last night, who have not been listed?

YES ___ (ADD TO TABLE)
NO ___

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

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
CO-WIFE 09
OTHER RELATIVE 10
ADOPTED/FOSTER/STEPCHILD 11
NOT RELATED 12
DON’T KNOW 98

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) stay here last night?

YES 1
NO 2

7. AGE
How old is (NAME)?
IF 95 OR MORE, RECORD ‘95’.

IN YEARS ______

8. IF AGE 15 OR OLDER -- MARITAL STATUS
What is (NAME)’s current marital status?

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

ELIGIBILITY: CHECK COLUMN 4 AND 7

9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

10. IF HOUSEHOLD SELECTED FOR MAN’S SURVEY
CIRCLE LINE NUMBER OF ALL MEN AGE 15-49

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

CHECK COLUMN 7, 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 was his name? RECORD FATHER’S LINE NUMBER. IF NO, RECORD ‘00’.

LINE NO. _____

CHECK COLUMN 7, IF AGE 0-4 YEARS
BIRTH REGISTRATION

16. Does (NAME) have a birth certificate? IF NO, PROBE: Has (NAME)’s birth ever been registered with the civil authority?

HAS CERTIFICATE 1
REGISTERED 2
NEITHER 3
DON’T KNOW 8

CHECK COLUMN 7, IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL

17. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20A)

18. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
SEE CODES BELOW.

LEVEL
PRE-PRIMARY 0
PRIMARY 1
POST PRIMARY TRAINING 2
SECONDARY ‘O’ LEVEL 3
POST SECONDARY ‘O’ LEVEL 4
SECONDARY ‘A’ LEVEL 5
POST SECONDARY ‘A’ LEVEL 6
UNIVERSITY 7
DON’T KNOW 8
GRADE
GRADE ____
LESS THAN 1 YEAR COMPLETED 00
DON’T KNOW 98

CHECK COLUMN 7, IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE

19. Did (NAME) attend school at any time during the 2015 school year?

YES 1
NO 2 (GO TO 20A)

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

LEVEL
PRE-PRIMARY 0
PRIMARY 1
POST PRIMARY TRAINING 2
SECONDARY ‘O’ LEVEL 3
POST SECONDARY ‘O’ LEVEL 4
SECONDARY ‘A’ LEVEL 5
POST SECONDARY ‘A’ LEVEL 6
UNIVERSITY 7
DON’T KNOW 8
GRADE
GRADE ___
DON’T KNOW 98

HEALTH INSURANCE

20A. Is (NAME) covered by any health insurance?

YES 1
NO 2 (GO TO 21)
DON’T KNOW 8 (GO TO 21)

20B. What is (NAME)’s main type of health insurance?
SEE CODES BELOW.

NHIF 0
NSSF 1
CHF 2
OTHER EMPLOYER BASED 3
OTHER COMMUNITY BASED/MUTUAL 4
PRIVATELY PURCHASED 5
OTHER (SPECIFY) _____ 6
DON’T KNOW 8

INPATIENT

21. In the last six months, was (NAME) admitted overnight to stay at a health facility?

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

22. CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR INPATIENT MODULE. CHECK COLUMN 21: CODE ‘1’ ‘YES’ CIRCLED.

OUTPATIENT

23. In the last four weeks, did (NAME) receive care from a health provider, a pharmacy, or a traditional healer without staying overnight?

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

24. The last time (NAME) received care, was any money paid?

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

25. CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR OUTPATIENT MODULE. CHECK COLUMN 24: CODE ‘1’ ‘YES’ CIRCLED.

HOUSEHOLD CHARACTERISTICS

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

PIPED WATER
PIPED INTO DWELLING 11
PIPED TO YARD/PLOT 12
PIPED TO NEIGHBOR 13
PUBLIC TAP/STANDPIPE 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 102)
BOTTLED WATER 91 (GO TO 102)
OTHER (SPECIFY) _____ 96 (GO TO 103)

101A. Which agency is providing water at your main source?

AUTHORITY 1 (GO TO 106)
CBO 2 (GO TO 106)
PRIVATE OPERATOR 3 (GO TO 106)
DON’T KNOW 8

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/STANDPIPE 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?

MINUTES _____
DON’T KNOW 998

104A.Who usually goes to the source to collect water for your household? PROBE: Is this person under age 15? What sex?

ADULT WOMAN (AGE 15+YEARS) 1
ADULT MAN (AGE 15+YEARS) 2
FEMALE CHILD (UNDER 15) 3
MALE CHILD (UNDER 15) 4
DON’T KNOW 8

105. CHECK 101 AND 102: CODE ‘14’ OR ‘21’ CIRCLED?

YES 1 (GO TO 106)
NO 2 (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 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 (WASHABLE) 22
PIT LATRINE WITH SLAB (NOT WASHABLE) 23
PIT LATRINE WITHOUT SLAB/OPEN PIT 24
COMPOSTING TOILET 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO TOILET/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 own 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/PLOT 2
ELSEWHERE 3

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

ELECTRICITY 01
BOTTLED GAS 02
PARAFFIN/KEROSENE 03
CHARCOAL 04
FIREWOOD 05
CROP RESIDUALS, STRAW, GRASS 06
ANIMAL DUNG 07
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 115A)
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 115A)
OUTDOORS 3 (GO TO 115A)
OTHER (SPECIFY) _____ 6 (GO TO 115A)

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

YES 1
NO 2

115A. What is the main source of energy for lighting in the household?

ELECTRICITY 01
SOLAR 02
GAS 03
PARAFFIN-HURRICANE LAMP 04
PARAFFIN-PRESSURE LAMP 05
PARAFFIN-WICK LAMP 06
FIREWOOD 07
CANDLES 08
OTHER (SPECIFY) _____ 96

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

ROOMS _____

116A. How many sleeping spaces such as mats, rugs, mattresses or beds are used in this household?

SLEEPING PLACES _____

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) Milk cows or bulls?
b) Other cattle?
c) Horses, donkeys, or mules?
d) Goats?
e) Sheep?
f) Chickens or other poultry?

a) COWS/BULLS _____
b) OTHER CATTLE _____
c) HORSES/DONKEYS/MULES _____
d) GOATS ______
e) SHEEP _____
f) CHICKENS/POULTRY _____

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

YES 1
NO 2 (GO TO 121)

120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLED ‘950’.

HECTARES ____._
95 OR MORE HECTARES 950
DON’T KNOW 998

121. Does your household have:

a) Electricity that is connected?
b) A radio in working condition?
c) A television in working condition?
d) A non-mobile telephone in working condition?
e) A computer in working conditions?
f) A refrigerator in working condition?
g) A battery or Generator for power?
h) An iron (charcoal or electricity)?

a) ELECTRICITY
YES 1
NO 2
b) RADIO
YES 1
NO 2
c) TELEVISION
YES 1
NO 2
d) NON-MOBILE TELEPHONE
YES 1
NO 2
e) COMPUTER
YES 1
NO 2
f) REFRIGERATOR
YES 1
NO 2
g) BATTERY
YES 1
NO 2
h) IRON
YES 1
NO 2

122. Does any member of this household own:

a) A watch?
b) A mobile phone?
c) A bicycle?
d) A motorcycle or motor scooter?
e) An animal-drawn cart?
f) A car or truck?
g) A boat with a motor?

a) WATCH
YES 1
NO 2
b) MOBILE PHONE
YES 1
NO 2
c) BICYCLE
YES 1
NO 2
d) MOTORCYCLE/SCOOTER
YES 1
NO 2
e) ANIMAL-DRAWN CART
YES 1
NO 2
f) CAR/TRUCK
YES 1
NO 2
g) BOAT WITH MOTOR
YES 1
NO 2

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

YES 1
NO 2

123A. How far is it to the nearest market place?
IF LESS THAN ONE KM, ENTER 00. IF MORE THAN 95 KM, ENTER 95.

KILOMETRES _____

124. How often does anyone smoke 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

124A. Now I would like to ask you about the food your household eats. How many meals does your household usually have per day?

MEALS ____

124B. In the past week, on how many days did the household eat meat or fish?

DAYS _____

124C. How often in the last years did you have problems in satisfying the food needs of the household?

NEVER 1
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5

124D. In the past four weeks, was there ever no food to eat of any kind in your household because of lack of resources to get food? Would you say it never happened? Rarely happened? Happened sometimes or often?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

124E. In the past four weeks, did you or any household member go to sleep at night hungry because there was not enough food? Would you say it never happened? Rarely happened? Happened sometimes or often?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

124F. In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food? Would you say it never happened? Rarely happened? Happened sometimes or often?

NEVER 1
RARELY 2
SOMETIMES 3
OFTEN 4

124G. How far is it to the nearest health facility?
IF LESS THAN ONE KM, ENTER ‘00’. IF MORE THAN 95 KM, ENTER ‘95’.

KILOMETRES ____

124H. If you were to go to the nearest health facility, how would usually you go there?

CAR/MOTORCYCLE 1
PUBLIC TRANSPORT (BUS, TAXI) 2
ANIMAL/ANIMAL CART 3
WALKING 4
BICYCLE 5
OTHER (SPECIFY) _____ 6

124I. Did your household ever receive any (NAME OF ASSISTANCE) from government or non-government organizations?

a) CASH ASSISTANCE
YES 1 (GO TO 124J)
NO 2 (GO TO 124Ib)
DON’T KNOW 8 (GO TO 124Ib)
b) FOOD ASSISTANCE
YES (GO TO 124J)
NO 2 (GO TO 124Ic)
DON’T KNOW 8 (GO TO 124Ic)
c) OTHER ASSISTANCE (SPECIFY) ______
YES 1 (GO TO 124J)
NO 2
DON’T KNOW 8

124J. What is the name of the organization or program that provided this assistance?

a) CASH ASSISTANCE
GOVERNMENT 1
NON GVT PROGRAM (SPECIFY) _____ 2
b) FOOD ASSISTANCE
GOVERNMENT 1
NON GVT PROGRAM (SPECIFY) _____ 2
c) OTHER ASSISTANCE (SPECIFY) _____
GOVERNMENT 1
NON GVT PROGRAM (SPECIFY) _____ 2

124J1. CHECK 124I, AT LEAST ONE YES CIRCLED?

YES (GO TO 124K)
NO (GO TO 125)

124K. When was the last time you received an assistance?
IF LESS THAN 2 YEARS, RECORD NUMBER OF MONTH. IF LESS THAN 1 MONTH, RECORD ‘00’.

MONTHS AGO 1 ____
YEARS AGO 2 _____

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

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 6 NETS, USE ADDITIONAL

OBSERVED 1
NOT OBSERVED 2

129A. IF NET OBSERVED, RECORD ITS COLOR(S). IF NET NOT OBSERVED, ASK: What color is the net?

SOLID BLUE 1
SOLID WHITE 2
BLUE AND WHITE STRIPED 3
OTHER (SPECIFY) _____ 6

130. How many months ago did your household 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)
PERMANENT 11
OLYSET 12
NETPROTEC 13
DURANET 14
OTHER/DON’T KNOW BRAND 16 (GO TO 134)
CONVENTIONAL POLYESTER NET 21
OTHER TYPE 96
DON’T KNOW TYPE 98

134. Did you get the net through Government’s net distribution campaign to households, during an antenatal care visit, during an immunization visit or through the school net programme (SNP)?

YES, NET DISTRIBUTION CAMPAIGN 1 (GO TO 136)
YES, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
YES, SNP 4 (GO TO 136)
NO 5

135. Where did you get the net?

GOVT. HEALTH FACILITY 01
PRIVATE HEALTH FACILITY 02
PHARMACY 03
ADDO 04
SHOP/MARKET 05
CHW 06
RELIGIOUS INSTITUTION 07
SCHOOL 08
OTHER 96
DON’T KNOW 98

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

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

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

NAME _______
LINE NO. ____

NAME _______
LINE NO. ____

NAME _______
LINE NO. ____

NAME _______
LINE NO. ____

GO BACK TO Q129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO Q139.

137A. Why not?
RECORD ALL MENTIONED.

NO MOSQUITOES A
NO MALARIA NOW B
TOO HOT C
DON’T LIKE SMELL D
FEEL CLOSED IN/AFRAID E
NET TOO OLD/TOR F
NET TOO DIRTY G
NET NOT AVAILABLE LAST NIGHT/NET BEING WASHED H
USUAL USER(S) DID NOT SLEEP HERE LAST NIGHT I
NET TOO SMALL J
SAVING NET FOR LATER K
NO LONGER KILLS/REPELS MOSQUITOES L
OTHER (SPECIFY) _____ X
DON’T KNOW Z

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

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

142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. 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 TALES, TERRAZZO 33
CEMENT/CONCRETE 34
CARPET 35
OTHER (SPECIFY) _____ 96

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

NATURAL ROOFING
NO ROOF 11
GRASS/THATCH/PALM LEAF/MUD 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANKS 23
FINISHED ROOFING
IRON SHEET 31
CONCRETE 32
TILES 33
OTHER (SPECIFY) _____ 96

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

NATURAL WALLS
NO WALL 11
GRASS 12
CANE/PALM/TRUNKS/BAMBOO 13
RUDIMENTARY WALLS
POLES WITH MUD 21
STONE WITH MUD 22
WOOD, TIMBER 23
FINISHED WALLS
CEMENT/CONCRETE 31
STONE WITH LIME/CEMENT 32
SUN-DRIED BRICKS/MUD BRICK 33
BAKED BRICKS 34
CEMENT BLOCKS 35
OTHER (SPECIFY) _____ 96

145. I would like to check whether the salt used in your household is iodized. May I have a sample of the salt used to cook meals in your household?
TEST SALT FOR IODINE.

IODINE PRESENT 1
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) _____ 6

146. CHECK COVER OF HOUSEHOLD QUESTIONNAIRE. IF HOUSEHOLD SELECTED FOR ADDITIONAL SALT TESTING ASK FOR ADDITIONAL FULL TABLESPOON OF SALT. PLACE SALT IN CONTAINER.

PUT THE 1ST BAR CODE LABEL HERE _____
PUT THE 2ND BAR CODE LABEL ON THE RESPONDENT’S CONTAINER OF SALT AND THE 3RD ON THE TRANSIMITAL FORM.

INPATIENT HEALTH EXPENDITURES MODULE

201. CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE:

ONE OR MORE INPATIENTS (GO TO 202)
NO INPATIENTS (GO TO 301)

202. CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE: ENTER THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO WAS AN INPATIENT. THEN ASK: Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last six months. (IF THERE ARE MORE THAN 3 INPATIENTS, USE ADDITIONAL QUESTIONNAIRE).

203. LINE NUMBER FROM COLUMN 22 IN HOUSEHOLD SCHEDULE

LINE NUMBER _____

204. NAME FROM COLUMN 2 IN HOUSEHOLD SCHEDULE

NAME __________

205. Where did (NAME) most recently stay overnight for health care?

GOVERNMENT/PARASTATAL
NATIONAL/ZONAL/SPECIALIZED HOSPITAL 21
REGIONAL REFERAL HOSPITAL 22
REGIONAL HOSPITAL 23
DISTRICT HOSPITAL 24
HEALTH CENTRE 25
DISPENSARY 26
CLINIC 27
CHW 28
RELIGIOUS/VOLUNTARY
REFERAL/SPECIALIZED HOSPITAL 31
DISTRICT HOSPITAL 32
HOSPITAL 33
HEALTH CENTRE 34
DISPENSARY 35
CLINIC 36
PRIVATE
SPECIALIZED HOSPITAL 41
HOSPITAL 42
HEALTH CENTRE 43
DISPENSARY 44
CLINIC 45
TRADITIONAL HEALER/ALTERNATIVE MEDEC. 46
OTHER (SPECIFY) _____ 96

206. What was the main reason for (NAME) to seek care this most recent time?

PREGNANCY/DELIVERY 01
ILLNESS 02
ACCIDENT/INJURY 03
OTHER (SPECIFY) _____ 06

207. How much money in total did you or any other member of your household spend on the treatment and services (NAME) received during the most recent overnight stay? We want to know about all the costs for the stay including

COST (TSH) _____
NO COST/FREE 00000000
IN KIND ONLY 99999995
DON’T KNOW 99999998

208. Did (NAME) stay overnight at a health facility another time in the last six months?

YES 1
NO 2 (GO TO 220)

209. Where did (NAME) stay the next-to-last time (he/she) stayed overnight for health care?

GOVERNMENT/PARASTATAL
NATIONAL/ZONAL/SPECIALIZED HOSPITAL 21
REGIONAL REFERAL HOSPITAL 22
REGIONAL HOSPITAL 23
DISTRICT HOSPITAL 24
HEALTH CENTRE 25
DISPENSARY 26
CLINIC 27
CHW 28
RELIGIOUS/VOLUNTARY
REFERAL/SPECIALIZED HOSPITAL 31
DISTRICT HOSPITAL (DDH) 32
HOSPITAL 33
HEALTH CENTRE 34
DISPENSARY 25
CLINIC 36
PRIVATE
SPECIALIZED HOSPITAL 41
HOSPITAL 42
HEALTH CENTRE 43
DISPENSARY 44
CLNIIC 45
TRADITONAL HEALER/ALTERNATIVE MEDEC. 46
OTHER (SPECIFY) _____ 96

210. What was the main reason for (NAME) to seek care this next-to-last time?

PREGNANCY/DELIVERY 01
ILLNESS 02
ACCIDENT/INJURY 03
OTHER (SPECIFY) _____ 06

211. How much money in total did you or any other member of your household spend on the treatment and services (NAME) received during the next-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory

COST (TSH) ________
NO COST/FREE 00000000
IN KIND ONLY 99999995
DON’T KNOW 99999998

212. Besides the two stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

YES 1
NO 2 (GO TO 220)

213. Where did (NAME) stay the second-to-last time (he/she) stayed overnight for health care?

GOVERNMENT/PARASTATAL
NATIONAL/ZONAL/SPECIALIZED HOSPITAL 21
REGIONAL REFERAL HOSPITAL 22
REGIONAL HOSPITAL 23
DISTRICT HOSPITAL 24
HEALTH CENTRE 25
DISPENSARY 26
CLINIC 27
CHW 28
RELIGIOUS/VOLUNTARY
REFERAL/SPECIALIZED HOSPITAL 31
DISTRICT HOSPITAL (DDH) 32
HOSPITAL 33
HEALTH CENTRE 34
DISPENSARY 25
CLINIC 36
PRIVATE
SPECIALIZED HOSPITAL 41
HOSPITAL 42
HEALTH CENTRE 43
DISPENSARY 44
CLNIIC 45
TRADITONAL HEALER/ALTERNATIVE MEDEC. 46
OTHER (SPECIFY) _____ 96

214. What was the main reason for (NAME) to seek care this second-to-last time?

PREGNANCY/DELIVERY 01
ILLNESS 02
ACCIDENT/INJURY 03
OTHER (SPECIFY) _____ 06

215. How much money did you or any other member of your household spend on the treatment and services (NAME) received during the second-to-last overnight stay? We want to know about all the costs for the stay, including

COST (TSH) ____________
NO COST/FREE 00000000
IN KIND ONLY 99999995
DON’T KNOW 99999998

216. Besides the three stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

YES 1
NO 2 (GO TO 220)

217. In total, how many times did (NAME) stay overnight in a health facility in the last six months?

NUMBER OF INPATIENT VISITS ____

220. GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 301.

SELECTION FOR OUTPATIENT HEALTH EXPENDITURES MODULE

301. CHECK COLUMN 25:

ONE OR MORE ELIGIBLE OUTPATIENTS (CONTINUE)
NO ELIGIBLE OUTPATIENTS (GO TO 311)

TABLE FOR SELECTION OF OUTPATIENT WHO PAID FOR CARE THE LAST TIME SOUGHT CARE IN THE LAST FOUR WEEKS

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 OUTPATIENTS (COLUMN 25) 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 PERSON SELECTED FOR THE OUTPATIENT QUESTIONS FROM THE LIST OF ELIGIBLE OUTPATIENTS IN COLUMN 25 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q302.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS ‘716’ AND THE HOUSEHOLD SCHEDULE COLUMN 25 SHOWS THAT THERE ARE THREE ELIGIBLE OUTPATIENTS 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 OUTPATIENTS 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 OUTPATIENT WHO IS ELIGIBLE FOR THE OUTPATIENT QUESTIONS (LINE NUMBER ‘04’ IN THIS EXAMPLE). WRITE THE NAME AND LINE NUMBER OF THE

*(see pdf for table)*

302.

NAME OF SELECTED OUTPATIENT _____
HH LINE NUMBER OF SELECTED OUTPATIENT ____

303. Now I would like to ask some questions about health care that (NAME IN 302) received in the last four weeks, without having to stay overnight. Where did (NAME) get care most recently without staying overnight?

GOVERNMENT/PARASTATAL
NATIONAL/ZONAL/SPECIALIZED HOSPITAL 21
REGIONAL HOSPITAL 22
REGIONAL HOSPITAL 23
DISTRICT HOSPITAL 24
HEALTH CENTRE 25
DISPENSARY 36
CLINIC 27
CHW 28
RELIGIOUS/VOLUNTARY
REFERAL/SPECIALIZED HOSPITAL 31
DISTRICT HOSPITAL 32
HEALTH CENTRE 33
DISPENSARY 34
CLINIC 35
PRIVATE
SPECIALIZED HOSPITAL 41
HOSPITAL 42
HEALTH CENTRE 43
DISPENSARY 44
CLNIC 45
TRADITIONAL HEALER/ALTERNATIVE MED. 46
PHARMACY 47
ADDO 48
OTHER (SPECIFY) ____ 96

304. How much money in total did you or any other member of your household spend on treatment and services (NAME) received from (NAME OF PROVIDER IN 303)? Please include the consulting fee and any expenses for other items including drugs and tests.

COST (TSH) ________
DON’T KNOW 999998

305. What was the main reason for (NAME) to seek care this most recent time?

FAMILY PLANNING 01
ANTENATAL CARE/DELIVERY/POSTNATAL CARE 02
MALARIA 03
FEVER 04
DIARRHEA 05
HIV/AIDS/STD 06
OTHER ILLNESS 07
CHECK-UP/PREVENTIVE CARE 08
ACCIDENT/INJURY 09
OTHER (SPECIFY) _____ 96
MISSING/DON’T KNOW 98

306. Did (NAME) get care another time in the last four weeks from a health provider, a pharmacy, or a traditional healer without staying overnight?

YES 1
NO 2 (GO TO 311)

307. How many other times did (NAME) get care in the last four weeks?

NUMBER OF OUTPATIENT VISITS ____

308. How many times was money spent?

NUMBER OF OUTPATIENT VISITS PAID MONEY ____

311. Sometimes people buy vitamins, medicines, and herbal remedies without consulting with a health provider, pharmacy, or traditional healer. They may also buy other health-related items such as Band-Aids/plasters, thermometers, or other medical devices, and so on without a consultation. In the last four weeks, how much money was spent on these types of health-related items for members of your household?

COST (TSH) ______
NONE 000000
IN KIND ONLY 999995
DON’T KNOW 999998

312A. CHECK COLUMN 9:

ONE OR MORE WOMEN AGE 15-49 YEARS OLD (CONTINUE)
NO WOMEN AGE 15-49 YEARS OLD (GO TO 313)

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
*(see pdf for table)*

NAME OF SELECTED WOMAN _____
HH LINE NUMBER OF SELECTED WOMAN ____

313. RECORD THE TIME.

HOURS ___
MINUTES ___
MORNING 1
AFTERNOON 2
EVENING 3

INTERVIEWER’S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW: _____________________________________________

COMMENTS ON SPECIFIC QUESTIONS: _________________________________________

ANY OTHER COMMENTS: ___________________________________________________

SUPERVISOR’S OBSERVATIONS ________________________________________________

EDITOR’S OBSERVATIONS ___________________________________________________