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2016 UGANDA DEMOGRAPHIC AND HEATLTH SURVEY
HOUSEHOLD QUESTIONNAIRE (ENGLISH)

UGANDA

UGANDA BUREAU OF STATISTICS

IDENTIFICATION

EA NAME_____

NAME OF HOUSEHOLD HEAD

CLUSTER NUMBER

HOUSEHOLD NUMBER

HOUSEHOLD SELECTED FOR MAN'S SURVEY AND BIOMARKER TESTING

1=YES
2=NO

HOUSEHOLD SELECTED FOR DV?

1=WOMEN
2=MAN

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER NAME
RESUT*

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. NU,
RESULT*

TOTAL NUMBER OF VISITS

*RESULT CODES

1 COMPLETED
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONSENT 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) __________

TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

LANGUAGE OF QUESTIONNAIRE** ____
LANGUAGE OF INTERVIEW** ____
NATIVE LANGUAGE OF RESPONDENT ** ____
TRANSLATOR USED (YES=1, NO=2) ___
LANGUAGE OF QUESTIONNAIRE** ______
**LANGUAGE CODES:

01 ENGLISH
02 LUGANDA
03 LUO
04 LUGBARA
05 ATESO
06 NGAKARIMOJONG
07 RUNYANKOLE/RUKIGA
08 RUNYORO/RUTORO
09 LUSOGA
96 OTHER (SPECIFY) ________

SUPERVISOR
NAME
NUMBER

CAPI MANAGER
NAME
NUMBER

INTRODUCTION AND CONSENT
Hello. My name is _______________________________________. I am working with Uganda Bureau of Statistics. We are conducting a survey about health and other topics all over Uganda. 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 30 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 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?
May I begin the interview now?

SIGNATURE OF INTERVIEWER:_____________________________DATE:______________

RESPONDENT AGREES TO BE INTERVIEWED 1 (CONTINUE)

100 RECORD THE TIME
HOURS ___ MINUTES _____

RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

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 QUESTONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLMNS 5-34 FOR EACH PERSON.

NAME_____

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

CODE FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

01 = HEAD
02 = WIFE OR HUSBAND
03 = SON OR DAUGHTER
04 = DON-IN-LAW OR DAUGHTER-IN-LAW
05 = GRANDCHILD
06 = PARENT
07 = PARENT-IN-LAW
08 = BROTHER OR SISTER
09 = OTHER RELATIVE
10 = ADOPTED/FOSTER/STEPCHILD
11 = NOT RELATED
98 = DON'T KNOW

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 95 OR MORE, RECORD '95'.

AGE IN YEARS ____

IF AGE 15 OR OLDER

8) MARITAL STATUS

What is (NAME)'s current marital status?

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

ELIGIBILITY

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

IF HOUSEHOLD SELECTED FOR MAN'S SURVEY

ELIGIBILITY

10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-54

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 NUMBER ___

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 NUMBER ___

IF AGE 5 YEARS OR OLDER

EVER ATTENDED SCHOOL

16) Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 21)

17) 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.

CODES FOR Qs. 17 AND 19: EDUCATION

LEVEL

0 = PRESCHOOL
1 = PRIMARY
2 = "O" LEVEL
3 = "A" LEVEL
4 = TERTIARY
5 = UNIVERSITY
6 = FAL
8 = DON'T KNOW

GRADE

00 = LESS THAN 1 YEAR COMPLETED (USE '00' FOR Q.17 ONLY. THIS CODE IS NOT ALLOWED FOR Q. 19)
98 = DON'T KNOW.
LEVEL
GRADE

IF AGE 5-24 YEARS

CURRENT/RECENT SCHOOL ATTENDENCE

18) Did (NAME) attend school at any time during the 2016 school year?

YES 1
NO 2 (GO TO 21)

19) During this school year, what level and grade is (NAME) attending? SEE CODES.

LEVEL
GRADE

IF AGE 0-4 YEARS

BIRTH REGISTRATION

20) Does (NAME) have a birth certification?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

SHORT CERTIFICATE SEEN 1
LONG CERTIFICATE SEEN 2
BIRTH CERTIFICATE NOT SEEN 3
REGISTERED, NO CERTIFICATE 4
NOT REGISTERED 5
DON'T KNOW 8

IF AGE 1-14 YEARS

DEWORMING

21) Did (NAME) take any medication on for intestinal worms in the past 6 months?

YES 1
NO 2
DON'T KNOW 8

IF FEMALE AGE 10-14 YEARS

HPV VACCINATION

22) Has (NAME) ever had the HPV vaccine to prevent cancer?

YES 1
NO 2
DON'T KNOW 8

IF AGE 5 OR OLDER

DISABILITY

23) Does (name) wear glasses or contact lenses to help them see?

YES 1
NO 2 (GO TO 25)

24) 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
SOME DIFFCULTY 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8

(GO TO 26)

25) 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 DIFFCULTY 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8

26) Does (NAME) wear a hearing aid?

YES 1
NO 2 (GO TO 28)

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

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

(GO TO 29)

28) 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 DIFFCULTY 2
A LOT OF DIFFICULTY 3
CANNOT HEAR AT ALL 4
DON'T KNOW 8

29) 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 difficult, 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

30) 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

31) 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 4
DON'T KNOW 8

32) 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 dress 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

IF AGE 2 OR OLDER

DISABILITY

33) Does (NAME) have any other difficulties that have lasted or are expected to last 6 months or more?

YES 1
NO 2 (GO TO NEXT ROW)
DON'T KNOW 3 (GO TO NEXT ROW)

34) What types of difficulties does (NAME) face?
LIST UP TO TWO DIFFICULTIES

CODES FOR Q. 34: DISABILITY

A = Limited use of legs, feet
B = No leg(s), feet
C = Limited use of arm(s), hand(s)
D = No arm(s), hand(s)
E = Facial mutilation (nose, lips, ears)
F = Serious problem with back spine
G = Hearing difficulty
H = Deafness
I = Serious speech impediment
J = Unable to speak
K = Poor vision
L = Blindness
M = Mental retardation
N = Mental illness
O = Frequent nightmares
P = Mood changes
Q = Feeling of helplessness
R = Epilepsy, fits
S = Chronic joint disease
T = Leprosy
U = Loss of feeling

SELECTION OF ONE CHILD FOR CHILD DISCIPLINE

SL1 CHECK COL.7 IN THE LIST OF HOUSEHOLD MEMBERS AND WRITE THE TOTAL NUMBER OF CHILDREN AGE 1-14 YEARS.

TOTAL NUMBER ____

SL2 CHECK THE NUMBER OF CHILDREN AGE 1-14 YEARS IN SL1

ZERO (SKIP TO SL10)
ONE (SKIP TO SL9 AND RECORD THE RANK NUMBER AS '1', ENTER THE LINE NUMBER, CHILD'S NAME AND AGE)
TWO OR MORE (GO RO SL2A)

SL2A LIST EACH OF THE CHILDREN AGE 1-14 YEARS BELOW IN THE ORDER THEY APPEAR IN THE IST OF HOUSEHOLD MEMBERS. DO NOT INCLUSE OTHER HOUSEHOLD MEMBERS OUTSIDE OF THE AGE RANGE 1-14 YEARS. RECORD THE LINE NUMBER, NAME, SEX, AND AGE FOR EACH CHILD.

SL3 RANK NUMBER

RANK
1
2
3
4
5
6
7
8
9

SL4 HH LINE NUMBER

LINE ____

SL5. NAME FROM COL.2

NAME ________

SL6. SEC FROM COL.4

M 1
F 2

SL7. AGE FROM COL. 7

AGE ____

SELECTION OF ONE CHILD FOR CHILD DISCIPLINE

SL8 HOW TO USE THE TABLE FOR SELECTION OF A CHILD

LAST DIFIT OF QUESTIONNAIRE SERIAL NUMBER ___
GO TO THIS ROW NUMBER

TOTAL NUMBER OF ELIGIBLE CHILDREN (SL1) __
(GO TO THIS COLUMN NUMBER)
IF ZERO, GO TO SL10

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 CHILDREN (SL1) ON THE PREVIOUS PAGE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED RO AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE RANK NUMBER OF THE CHILD SELECTED FOR THE CHILD LABOUR/CHILD DISCIPLINE QUESTIONS FROM THE BOX OF ELIGIBLE CHILDREN IN (SL3). WRITE THE NAME, LINE NUMBER, AND RANK NUMBER OF THE SELECTED CHILD IN THE SPACE BELOW THAT TABLE.

EXAMPLE: THE HOUSEHOLD NUMBER IS '716' AND (SL1) SHOWS THAT THERE ARE THREE ELIGIBLE CHILDREN AGE 1-14 IN THE HOUSEHOLD. SINCE THE LAST DIGIT OF THE HOUSEHOLD NUMBER IS '6'GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE CHILDREN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN FIND THE SECOND CHILD. WRITE THE NAME, LINE NUMBER, AND RANK NUMBER OF THE CHILD IN THE SPACE ELOW THE TABLE.

LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER

0
1
2
3
4
5
6
7
8

TOTAL NUMBER OF ELIGIBLE CHILDREN AGE 1-14 IN HOUSEHOLD FORM (SL1)
1
2
3
4
5
6
7
8+

SL9 NAME OF SELECTED CHILD: _______
HH LINE NUMBER OF SELECTED CHILD: ____
RANK NUMBER OF SELECTED CHILD: _____

SELECTION OF INDIVIDUAL FOR DOMESTIC VIOLENCE QUESTIONS

SL10 ONLY ONE INDIVIDUAL (ONE WOMAN OR ONE MAN) SHOULD BE SELECTED FOR DOMESTIC VIOLENCE QUESTIONS

CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR MAN'S SURVEY AND BIOMARKER TESTING?

NO (CONTINUE)
YES (GO TO SL13)

SL11 TABLE FOR SELECTION OF WOMEN FOR DOMESTIC VIOLENCE QUESTIONS
HOW TO USE THE TABLE FOR SELECTION OF A RESPONSENT

LAST DIGIT OF QUESTIONNAIRE SERIAL NUMBER __
GO TO THIS ROW NUMBER

TOTAL NUMBER OF ELIGBLE WOMEN (COL 9) ___
(GO TO THIS COLUMN NUMBER)
IF ZERO, GO TO CD2

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 DOMEXTIC 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 THREE ELIGIBLE WOMEN IN THE HOUDEHOLD, 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.

LAST DIGIT OF THE HOUSEHOLD QUESTIONAIRE SERIAL NUMBER
1
2
3
4
5
6
7
8
9

TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 9
1
2
3
4
5
6
7
8+

SL12 NAME OF SELECTED WOMAN: __
HH LINE NUMBER OF SELECTED WOMAN: __
(GO TO CS2)

SL13 TABLE FOR SELECTION OF MEN FOR DOMESTIC VIOLENCE QUESTIONS

HOW TO USE THE TABLE FOR SELECTION OF A RESPONDENT

LAST DIGIT OF QUESTIONNAIRE SERIAL NUMBER __
(GO TO THIS ROW NUMBER)

TOTAL NUMBER OF ELIGIBLE MEN (COL 10)
(GO TO THIS COLIMN NUMBER)
IF ZERO, GO TO CD2)

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 MEN (COLUMN 10) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND CLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER FO THE MAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE MEN IN COLUMN 10 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED MAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLDQUESTIONAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 10 SHOWS THAT THERE ARE THREE ELIGIBLE MEN AGE 15-54 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 WLIGIBLE MEN 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 MAN WHO IS ELIGIBLE FOR THE MAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HIS NAME AND LINENUMBER IN THE SPACE BELOW THE TABLE.

LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER
0
1
2
3
4
5
6
7
8
9

TOTAL NUMBER OF ELIGIBLE MEN AGE 15-54 IN HOUSEHOLD SCHEDULE COLUMN 10
1
2
3
4
5
6
7
8+

SL14 NAME OF SELECTED MAN:____
HH LIE NUMBER OF SELECTED MAN: ___

CHILD DISCIPLINE

CD2) WRITE THE LINE NUMBER AND NAME OF THE CHILD FORM SL9

LINE NUMBER ____
NAME ________

CD3) Adults use certain ways to teach children the right behavior or to address a behavior problem. I will read various methods that are used. Please tell me if you or anyone else in the house hold has used this method with (NAME) in the past month.

a) Took away privileges, forbade something (NAME) liked or did not allow (him/her) to leave the house.
YES 1
NO 2
b) Explained why (NAME)'s behavior was wrong.
YES 1
NO 2
c) Shook (him/her)
YES 1
NO 2
d) Shouted, yelled at or screamed at (him/her)
YES 1
NO 2
e) Gave (him/her)something else to do.
YES 1
NO 2
f) Spanked, hit or slapped (him/her) on the bottom with bare hand.
YES 1
NO 2
g) Hit (him/her) on the bottom or elsewhere on the body with something like a belt, hairbrush, stick, or other hard object.
YES 1
NO 2
h) Called (him/her) dumb, lazy, or another name like that.
YES 1
NO 2
i) Hit or slapped (him/her) on the face, head, or ears.

YES 1
NO 2

j) Hit or slapped (him/her) on the hand, arm, or leg.
YES 1
NO 2
k) Beat him/her up, that is hit (him/her) over as hard as one could.
YES 1
NO 2

CD4) Do you believe that in order to ring up, raise or educated a child properly, the child needs to be physically punished?

YES 1
NO 2
DON'T KNOW/ NO OPINION 8

CD4A) To the best of our knowledge, is there a government law that prohibits one from abusing a child?

YES 1
NO 2
DON'T KNOW 8

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/STANDPIPE 14 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTEXTED 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)
BICYCLE WITH JERRYCANS 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91
SACHET WATER 92
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/STANDPIPE 14
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTEXTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
BICYCLE WITH JERRYCANS 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

105) CHECK 101 AND 102: CODES '14' OR '21' CIRCLED?

YES (CONTINUE)
NO (GO TO 107)

106) In the past two weeks, was the water form 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 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET/ECOSAN 31
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/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 HOUSEHOLD 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
LPG/CYLINDER GAS 02
BIOGAS 04
KEROSENE 05
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

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, herd, 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) Local cattle?
NUMBER ___
b) Exotic/cross-breed cattle?
NUMBER ___
c) Horses, donkeys, or mules?
NUMBER ___
d) Goats?
NUMBER ___
e) Sheep?
NUMBER ___
f) Chickens or other poultry?
NUMBER ___
g) Pigs?
NUMBER ___

118A) Are there any animals that sleep in the house where people sleep?

YES 1
NO 2

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

YES 1
NO 2 (GO TO 120A)

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

IF 95 OR MORE, CIRCLE '950'

ACRES ___.___
95 OR MORE ACRES 950
DON'T KNOW 998

120A) Does any member of this household own any non-agricultural land?

YES 1
NO 2

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 computer?
YES 1
NO 2
f) A refrigerator?
YES 1
NO 2
g) A cassette/CD/DVD player?
YES 1
NO 2
h) A table?
YES 1
NO 2
i) A chair?
YES 1
NO 2
j) A sofa set?
YES 1
NO 2
k) A bed?
YES 1
NO 2
m) A clock?
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?
YES 1
NO 2
g) A boat with a motor?
YES 1
NO 2
h) A boat without a motor?
YES 1
NO 2

123) Does any member of this household have a bank account, mobile money account, or account with an agent?

YES 1
NO2

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

125) At any time in the past 6 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?

PROBE FOR ANY OTHERS. RECORD ALL MENTIONED.

GOVERNMENT WORKER/PROGRAM A
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER (SPECIFY)________ X
DON'T KNOW Z

126A) Did you pay for your dwelling to be sprayed?

YES 1
NO 2
DON'T KNOW 8

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 ___

MOSQUITO NETS

129) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD.

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

NET #1
OBSERVED 1
NOT OBSERVED 2
NET #2
OBSERVED 1
NOT OBSERVED 2
NET #3
OBSERVED 1
NOT OBSERVED 2

130) How many months ago did your household get the mosquito net?

IF LESS THAN ONE MONTH AGO, RECORD '00'

NET #1
MONTHS AGO __
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
NET #2
MONTHS AGO __
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
NET #3
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.

NET #1
LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
DURANET 12 (GO TO 134)
INTERCEPTOR 13 (GO TO 134)
NETPROTECT 14 (GO TO 134)
OLYSET 15 (GO TO 134)
DAWNET 16 (GO TO 134)
ICONLIFE 17 (GO TO 134)
YORKOOL 18 (GO TO 134)
DK BRAND 19 (GO TO 134)
GOVT BRAND 20 (GO TO 134)
OTHER (SPECIFY) ____ 21 (GO TO 134)

OTHER BRAND 96

DK BRAND 98
NET #2
LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
DURANET 12 (GO TO 134)
INTERCEPTOR 13 (GO TO 134)
NETPROTECT 14 (GO TO 134)
OLYSET 15 (GO TO 134)
DAWNET 16 (GO TO 134)
ICONLIFE 17 (GO TO 134)
YORKOOL 18 (GO TO 134)
DK BRAND 19 (GO TO 134)
GOVT BRAND 20 (GO TO 134)
OTHER (SPECIFY) ____ 21 (GO TO 134)

OTHER BRAND 96

DK BRAND 98
NET #3
LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11 (GO TO 134)
DURANET 12 (GO TO 134)
INTERCEPTOR 13 (GO TO 134)
NETPROTECT 14 (GO TO 134)
OLYSET 15 (GO TO 134)
DAWNET 16 (GO TO 134)
ICONLIFE 17 (GO TO 134)
YORKOOL 18 (GO TO 134)
DK BRAND 19 (GO TO 134)
GOVT BRAND 20 (GO TO 134)
OTHER (SPECIFY) ____ 21 (GO TO 134)

OTHER BRAND 96

DK BRAND 98

132) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

NET #1
YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)
NET #2
YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)
NET #3
YES 1
NO 2 (GO TO 134)
NOT SURE 8 (GO TO 134)

133) How many months ago was the net last soaked or dipped?

IF LESS THAN ONE MONTH AGO, RECORD '00'.

NET #1
MONTHS AGO ____
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
NET #2
MONTHS AGO ____
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
NET #3
MONTHS AGO ____
MORE THAN 24 MONTHS AGO 95
NOT SURE 98

134) Did you get the net through a mass distribution, during an antenatal care visit, or during an immunization visit?

NET #1
YES, MASS DISTRIBUTION 1 (GO TO 136)
YES, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4
NET #2
YES, MASS DISTRIBUTION 1 (GO TO 136)
YES, ANC 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4
NET #3
YES, MASS DISTRIBUTION 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?

NET #1
PUBLIC SECTOR
GOVT. HOSPITAL 11
GOVT. HEALTH FACILITY 12
PNFP/NGO
HOSPITAL 21
HEALTH FACILITY 22
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC 31
PHARMACY 32
OTHER SOURCE
SHOP/MARKET 41
HAWKER 42
CHW 43
RELIGIOUS INSTITUTION 44
OTHER 96
DON'T KNOW 98
NET #2
PUBLIC SECTOR
GOVT. HOSPITAL 11
GOVT. HEALTH FACILITY 12
PNFP/NGO
HOSPITAL 21
HEALTH FACILITY 22
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC 31
PHARMACY 32
OTHER SOURCE
SHOP/MARKET 41
HAWKER 42
CHW 43
RELIGIOUS INSTITUTION 44
OTHER 96
DON'T KNOW 98
NET #3
PUBLIC SECTOR
GOVT. HOSPITAL 11
GOVT. HEALTH FACILITY 12
PNFP/NGO
HOSPITAL 21
HEALTH FACILITY 22
PRIVATE SECTOR
PRIVATE HOSPITAL/CLINIC 31
PHARMACY 32
OTHER SOURCE
SHOP/MARKET 41
HAWKER 42
CHW 43
RELIGIOUS INSTITUTION 44
OTHER 96
DON'T KNOW 98

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

NET #1
YES 1
NO 2 (SKIP TO 138)
NOT SURE 8 (SKIP TO 138)
NET # 2
YES 1
NO 2 (SKIP TO 138)
NOT SURE 8 (SKIP TO 138)
NET #3
YES 1
NO 2 (SKIP TO 138)
NOT SURE 8 (SKIP TO 138)

137) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.

NET #1
NAME _____
LINE NO. ___
NET #2
NAME _____
LINE NO. ___
NET #3
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 ONSERVED, 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 PLANKS 21
PALM/BAMBOO 22
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
CONCRETE 32
CERAMIC TILES 33
CEMENT SCREED 34
CARPET 35
STONES 36
BRICKS 37
OTHER (SPECIFY) _____ 96

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

RECORD OVSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
MUD 13
RUDIMENTARY ROOFING
RUSTIC MAT 21
TINS 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED ROOFING
IRON SHEETS 31
WOOD 32
ASBESTOS 33
TILES 34
CONCRETE 35
ROOFING SHINGLES 36
OTHER (SPECIFY) ____ 96

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

RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
THATCHED/STRAW 12
DIRT 13
RUDIMENTARY WALLS
POLES WITH MUD 21
STONE WITH MUD 22
UNBURNT BRICKS WITH MUD 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
UNBURNT BRICKS WITH PLASTER 27
BURNT BRICKS WITH MUD 28
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BURNT BRICKS WITH CEMENT 33
CEMENT BLOCKS 34
UNBURNT BRICKS WITH CEMENT 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) ____ 96

144A) Where do you and your family mainly go for health care?

PROBE TO IDENTIFY TYPE OF SOURCE.

IF UNABLE TO DETERMINE IF PUBLIC OR PRIVATE SECTOR, WRITE THE NAME OF THE PLACE.

(NAME OF PLACE) _____________
PUBLIC SECTOR
GOVERNMENT HOSPITAL 11
GOVERNMENT HEALTH CENTER 12
FAMILY PLANNING CLINIC 13
MOBILE CLINIC 14
OTHER PUBLIC SECTOR (SPECIFY) ____________16
PRIVATE MEDICAL SECTOR
PRIVATE HOSPITAL/CLINIC 21
PRIVATE DOCTOR 22
MOBILE CLINIC 23
OTHER PRIVATE MEDICAL SECTOR (SPECIFY) _______26
OTHER (SPECIFY) ____96

DON'T KNOW 98

144B) Do you pay any money for the services offered?

YES, OFFICIAL FEES 1
YES, TOKEN OF THANKS 2
NO 3 (GO TO 145)
DON'T KNOW 8 (GO TO 145)

144C) How do you make the payment?

PROBE FOR ANY OTHERS. RECORD ALL MENTIONED.

DIRECTLY OUT OF POCKET A
COMMUNITY-BASED INITIATIVE/SAVINGS B
HEALTH INSURANCE THROUGH EMPLOYER C
SOCIAL SECURITY D
OTHER PRIVATELY PURCHASED COMMERCIAL HEALTH INSURANCE E
OTHER (SPECIFY) __________ X

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

ROAD TRAFFIC ACCIDENTS

A01) Now I would like to ask you about road traffic accidents that anyone in your household may have been involved in during the last 12 months.

Was anyone in your household killed in a road traffic accident in the past 12 months or injured in a road traffic accident with injuries severe enough that for at least one day they could not carry out their normal daily activities?

YES 1
NO 2 (GO TO A12)

A02) What is the name of the persons injured or killed?

ENTER THE NAME OF EACH PERSON INJURED OR KILLED IN A03.
OF THERE ARE MORE THAN TWO PERSONS, USE ADDITIONAL QUESTIONNAIRE(S).

A03) ENTER THE NAME OF EACH PERSON INJURED OR KILLED

RECORD HOUSEHOLD LINE NUMBER FROM COLUMN 1. RECORD '00' IF PERSON NOT LISTED IN HOUSEHOLD.

NAME ____
LINE NUMBER ____
NOT IN HOUSEHOLD 00

A04) Was (NAME) in a car, truck, bus, motorcycle, bicycle, another kind of vehicle, or a pedestrian?

IF A PERSON HAD MORE THAN ONE ROAD TRAFFIC ACCIDENT, ASK QUESTIONS ABOUT THE MOST RECENT ACCIDENT ONLY.

CAR 01
TRUCK 02
BUS 03
MOTORCYCLE 04
BICYCLE 05
PEDESTRIAN 06
OTHER (SPECIFY) ____96
DON'T KNOW 98

A04A) CHECK A03 LINE NUMBER:

00 (CONTUINE)
OTHER (SKIP TO A10)

A05) Is (NAME) still alive?

YES 1 (SKIP TO A09A)
NO 2
DON'T KNOW 8 (SKIP TO A09A)

A06) Was (NAME)'s death related to the road traffic accident?

YES 1
NO 2

A06A) Was (NAME)'s death registered with the civil authority?

YES 1
NO 2
DON'T KNOW 8

A07) Was (NAME) male or female?

MALE 1
FEMALE 2

A08) What was (NAME)'s age when (NAME) died?
IF LESS THAN ONE YEAR, RECORD '00'.

YEARS ____ (SKIP TO A11)
DON'T KNOW 98 (SKIP TO A11)

A09A) Is (NAME) male or female?

MALE 1
FEMALE 2

A09B) How old is (NAME)?
IF LESS THAN ONE YEAR, RECORD '00'

YEARS ____
DON'T KNOW 98

A10) What kind of injuries did (NAME) have as a result of the accident?

RECORD ALL MENTIONED.

PARALYZED A
BRAIN DAMAGE B
DISFIGUREMENT C
LOSS OF LIMB D
LOSS OF LIMB FUNCTION E
LOSS OF EYE SIGHT F
CHRONIC PAIN G
BURN H
CUTS I
BROKEN BONE J
EMOTIONAL TRAUMA K
OTHER (SPECIFY) X

A11) GO BACK TO A04 IN NEXT COLUMN, OR IF NO MORE PERSONS WITH ACCIDENTS, GO TO A12.

INJURIES

A12) Now I would like to ask you about other incidents that anyone in your household may have been involved in during the last 12 months.

Was anyone in your household killed in the last 12 months or injured in any other incident such as a fire, violent attack, animal bite, fall, drowning or anything else with injuries severe enough that for at least one day that could not carry out their normal daily activities?

YES 1
NO 2 (GO TO A23)

A13) What is the name of the person(s) injured or killed?

Enter the name of each person injured or killed in A14.
IF THERE ARE MORE THAN TWO PERSONS, USE ADDITIONAL QUESTIONNAIRE(S).

A14) ENTER THE NAME OF EACH PERSON INJURED OR KILLED: RECORD HOUSEHOLD LINE NUMBER FROM COLUMN 1. RECORD '00' IF PERSON NOT LISTED IN HOUSEHOLD.

NAME _________
LINE NUMBER ____
NOT IN HOUSEHOLD 00

A15) In what type of incident was (NAME) injured or killed?

VIOLENCE/ASSAULT 01
FIRE/BURNING 02
ANIMAL BITE 03
ACCIDENTAL FALL 04
DROWNING 05
POISONING 06
OTHER (SPECIFY) ______ 96
DON'T KNOW 98

A15A) CHECK A14 LINE NUMBER:

00 CONTINUE
OTHER (SKIP TO A20A)

A16) Is (NAME) still alive?

YES 1 (SKIP TO A20A)
NO 2

A17) Was (NAME)'s death related to this incident?

YES 1
NO 2
DON'T KNOW 8

A17A) Was (NAME)'s death registered with the civil authority?

YES 1
NO 2
DON'T KNOW 8

A18) Was (NAME) male or female?

MALE 1
FEMALE 2

A19) What was (NAME)'s age when (NAME) died?
IF LESS THAN ONE YEAR, RECORD '00'.

YEARS ____ (SKIP TO A22)
DON'T KNOW 98 (SKIP TO A22)

A20A) Is (NAME) male or female?

MALE 1
FEMALE 2

A20B) How old is (NAME)?

YEARS ____

A21) What kind of injuries did (NAME) have as a result of the incident?

RECORD ALL MENTIONED.

PARALYZED A
BRAIN DAMAGE B
DISFIGUREMENT C
LOSS OF LIMB D
LOSS OF LIMB FUNCTION E
LOSS OF EYE SIGHT F
CHORNIC PAIN G
BURN H
CUTS I
BROKEN BONE J
EMOTIONAL TRAUMA K
OTHER (SPECIFY) ____________ X

A22) GO BACK TO A15 IN NEXT COLUMN, OR IF NO MORE PERSONS WITH INJURIES, GO TO A23.

DEATHS

A23) CHECK A05 AND A16:
DEATHS DUE TO RTA OR OTHER INCIDENTS: a) Apart from anyone in your household that you already mentioned that was killed in a road traffic accident or other incident, has any other member of your household died in the last 12 months?
NO DEATHS: b) Has any member of your household died in the last 12 months?

YES 1
NO 2

A24) What is the name of the other person(s) who died?

ENTER THE NAME OF EACH PERSON WHO DIED IN A25.
IF THERE ARE MOREN THAN TWO PERSONS, USE ADDITIONAL QUESTIONNAIRE(S).

A25) ENTER THE NAME OF EACH PERSON WHO DIED:

NAME _______

A26) Was (NAME) male or female?

MALE 1
FEMALE 2

A27) What was (NAME)'s age when (NAME) died?

IF LESS THAN ONE YEAR, RECORD '00'.

YEARS ___
DON'T KNOW 98

A28) What was the cause of (NAME)'s death?

ILLNESS 01
AGE 02
NON-TRAFFIC ACCIDENT 03
ASSAULT/VIOLENCE 04
WITCHCRAFT 05
OTHER (SPECIFY) ______96
DON'T KNOW 98

A29) Where did (NAME)'s death take place?

HEALTH FACILITY 01
ON WAY TO HEALTH FACILITY 02
HOUSE/OTHER HOUSE 03
OUTSIDE 04
OTHER (SPECIFY) _____ 96
DON'T KNOW 98

A30) Was (NAME)'s death registered with the civil authority?

YES 1
NO 2
DON'T KNOW 8

A31) GO BACK TO A26 IN NEXT COLUMN, OR IF NO MORE PERSONS WHO DIED, GO TO A32.

ELIGIBILITY AND CONSENT FOR DISABILITY SURVEY

A32) CHECK COLUMNS 24-25 AND Q 27-32 FOR ANY HOUSEHOLD MEMBER WITH A RESPONSE OF '2-SOME DIFFICULTY', '2-A LOT OF DIFFICULTY', OR '4-CANNOT AT ALL' IN ANY OF THE COLIMNS.

ANY RESPONSE OF 2,3, OR 4 (CONTINUE)
ALL RESPONSES 1 OR 6 (SKIP TO 146)

A33) At a later point in time, my colleagues who are working with the Uganda Bureau of Statistics would like to revisit your household to conduct a study on disabilities. The study team will conduct a brief interview to assess the impact of disabilities on individuals and households. You don't have to permit the visit, but we hope you will agree since your household participation is very important. Your responses will remain confidential.

Do you have any question? Do you agree for your household to be revisited?

SIGNATURE OF INTERVIEWER ______
DATE ____
RESPONDENT AGREES TO BE REVISITED 1

RECORD THE TIME

RESPONDENT DOES NOT AGREE TO BE REVISITED 2

HOURS
MINUTES

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
______________________________________________________________________________
______________________________________________________________________________
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