HOUSEHOLD QUESTIONNAIRE
PLACE NAME ________
NAME OF HOUSEHOLD HEAD ______________
CLUSTER NUMBER ________
PSU NUMBER ________________
DWELLING UNIT NUMBER ________
HOUSEHOLD NUMBER ____
HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKERS?
NO 2
HOUSEHOLD SELECTED FOR SALT SAMPLE COLLECTION?
NO 2
FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOUSEHOLD AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _______ 9
NEXT VISIT:
DATE ____
TIME ____
SECOND VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOUSEHOLD AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _______ 9
NEXT VISIT:
DATE____
TIME____
THIRD VISIT
DATE____
INTERVIEWER'S NAME____
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOUSEHOLD AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _______ 9
FINAL VISIT
DAY____
MONTH____
YEAR ____
INT. NUMBER____
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOUSEHOLD AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) _______ 9
TOTAL NUMBER OF VISITS____
TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
TOTAL CHILDREN ELIGIBLE FOR CHILD QUESTIONNAIRE ____
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ____
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW ____
AFRIKAANS 02
isiXHOSA 03
isiZULU 04
SeSOTHO 05
SeTSWANA 06
SePEDI 07
SiSWATI 08
TshiVENDA 09
XITSONGA 10
isiNDEBELE 11
HOME LANGUAGE OF RESPONDENT ____
AFRIKAANS 02
isiXHOSA 03
isiZULU 04
SeSOTHO 05
SeTSWANA 06
SePEDI 07
SiSWATI 08
TshiVENDA 09
XITSONGA 10
isiNDEBELE 11
TRANSLATOR USED
NO 2
SUPERVISOR
NAME ____
NUMBER ____
Hello. My name is ________. I am working with Statistics South. We are conducting a survey about health and other topics all over South Africa. 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 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. 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 DOES NOT AGREE TO BE INTERVIEWED 2 (END)
MINUTES ____
1) LINE NUMBER:
2) USUAL RESIDENTS AND VISITORS:
Please give me the names of the persons who 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 5-28 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?
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?
NO
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO
3) RELATIONSHIP TO HEAD OF HOUSEHOLD:
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
02 WIFE/HUSBAND/PARTNER
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
08 BROTHER OR SISTER
09 OTHER RELATIVE
10 ADOPTED
11 FOSTER
12 STEP CHILD
13 NOT RELATED
98 DON'T KNOW
4) SEX:
Is (NAME) male or female?
FEMALE 2
RESIDENCE:
5) Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
6A) What is (NAME)'s date of birth? On what day, month, and year was (NAME) born?
IF DON'T KNOW DAY, RECORD '98'.
IF DON'T KNOW MONTH, RECORD '98'.
IF DON'T KNOW YEAR, RECORD '9998'.
MONTH ____
YEAR ________
7) AGE:
How old is (NAME)?
IF 95 OR MORE, RECORD '95'.
COMPARE AND CORRECT 6A AND/OR 7 IF INCONSISTENT.
IF AGE 15 OR OLDER:
8) MARITAL STATUS:
What is (NAME)'s current marital status?
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER-MARRIED AND NEVER LIVED TOGETHER 4
ELIGIBILITY:
9) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 OR, IF HOUSEHOLD SELECTED FOR MALE SURVEY BIOMARKERS, CIRCLE LINE NUMBER OF ALL WOMEN AGE 15 AND OLDER
9A) CIRCLE LINE NUMBER OF ALL WOMEN AGE 18 AND OLDER
10) IF HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKERS:
CIRCLE LINE NUMBER OF ALL MEN AGE 15 AND OLDER
11) IF HOUSEHOLD SELECTED FOR MALE SURVEY AND BIOMARKERS:
CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
IF AGE 0-17 YEARS:
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:
12) Is (NAME)'s biological mother alive?
NO 2 (GO TO 14)
DON'T KNOW 8 (GO TO 14)
13) Does (NAME)'s biological 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'.
14) Is (NAME)'s biological father alive?
NO 2 (GO TO 15A)
DON'T KNOW (GO TO 15A)
15) Does (NAME)'s biological father usually live in this household or was he a guest last night? IF YES: What is his name?
RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.
IF AGE 0-5 YEARS:
ELIGIBILITY:
15A) CHECK 13: IF MOTHER LIVES IN HOUSEHOLD, SKIP TO 16.
IF MOTHER HAS DIED OR DOES NOT LIVE IN THE HOUSEHOLD, CIRCLE LINE NUMBER OF CHILD.
15B) Who is the primary caregiver of (NAME)?
RECORD CAREGIVER'S LINE NUMBER.
IF AGE 5 YEARS OR OLDER:
EVER ATTENDED SCHOOL:
16) Has (NAME) ever attended an educational institution?
NO 2 (GO TO 20)
17) What is the highest level of education (NAME) has attended? What is the highest grade (NAME) completed at that level?
SEE CODES BELOW.
CODES FOR QUESTIONS 17 AND 19: EDUCATION:
01 GRADE R/GRADE 0/RECEPTION
11 GRADE 1/SUB A/CLASS 1
12 GRADE 2/SUB B/CLASS 2
13 GRADE 3/STANDARD 1/AET 1 (KHA RI GUDE, SANLI)
14 GRADE 4/STANDARD 2
15 GRADE 5/STANDARD 3/AET 2
16 GRADE 6/STANDARD 4
17 GRADE 7/STANDARD 5/AET 3
21 GRADE 8/STANDARD 6/FORM 1/NTC 1/N1/NC (V) LEVEL 2
22 GRADE 9/STANDARD 7/FORM 2/AET 4/NTC 2/N2/NC (V) LEVEL 3
23 GRADE 10/STANDARD 8/FORM 3/NTC 3/ N3/NC (V) LEVEL 4
24 GRADE 11/STANDARD 9/FORM 4
25 CERTIFICATE OF DIPLOMA WITH LESS THAN GRADE 12/STANDARD 10 COMPLETED
26 GRADE 12/STANDARD 10/FORM5/MATRIC
27 N4/NTC4
28 N5/NTC5
29 N6/NTC6
31 CERTIFICATE OF DIPLOMA WITH GRADE 12/STANDARD 10 COMPLETED
32 HIGHER DIPLOMA (TECHNIKOM/UNIVERSITY OF TECHNOLOGY)
33 POST HIGHER DIPLOMA (TECHNIKON/UNIVERSITY OF TECHNOLOGY MASTERS, DOCTORAL)
34 BACHELORS DEGREE/BACHELORS DEGREE AND POST GRADUATE DIPLOMA
35 HONOURS DEGREE
36 HIGHER DEGREE (MASTERS, DOCTORATE)
IF AGE 5-24 YEARS:
CURRENT/RECENT SCHOOL ATTENDANCE:
18) Did (NAME) attend an educational institution at any time during the 2016 academic year?
NO 2 (GO TO 20)
19) During (this/that) academic year, what level/grade [is/was] (NAME) attending?
SEE CODES BELOW
CODES FOR QUESTIONS 17 AND 19: EDUCATION:
01 GRADE R/GRADE 0/RECEPTION
11 GRADE 1/SUB A/CLASS 1
12 GRADE 2/SUB B/CLASS 2
13 GRADE 3/STANDARD 1/AET 1 (KHA RI GUDE, SANLI)
14 GRADE 4/STANDARD 2
15 GRADE 5/STANDARD 3/AET 2
16 GRADE 6/STANDARD 4
17 GRADE 7/STANDARD 5/AET 3
21 GRADE 8/STANDARD 6/FORM 1/NTC 1/N1/NC (V) LEVEL 2
22 GRADE 9/STANDARD 7/FORM 2/AET 4/NTC 2/N2/NC (V) LEVEL 3
23 GRADE 10/STANDARD 8/FORM 3/NTC 3/ N3/NC (V) LEVEL 4
24 GRADE 11/STANDARD 9/FORM 4
25 CERTIFICATE OF DIPLOMA WITH LESS THAN GRADE 12/STANDARD 10 COMPLETED
26 GRADE 12/STANDARD 10/FORM5/MATRIC
27 N4/NTC4
28 N5/NTC5
29 N6/NTC6
31 CERTIFICATE OF DIPLOMA WITH GRADE 12/STANDARD 10 COMPLETED
32 HIGHER DIPLOMA (TECHNIKOM/UNIVERSITY OF TECHNOLOGY)
33 POST HIGHER DIPLOMA (TECHNIKON/UNIVERSITY OF TECHNOLOGY MASTERS, DOCTORAL)
34 BACHELORS DEGREE/BACHELORS DEGREE AND POST GRADUATE DIPLOMA
35 HONOURS DEGREE
36 HIGHER DEGREE (MASTERS, DOCTORATE)
20) PROBLEM OF VISION
Does (NAME) have difficulty seeing, even if wearing glasses?
IF NO, CIRCLE "0".
IF YES, PROBE: With some difficulty, with a lot of difficulty, or cannot see at all?
IF SOME WITH SOME DIFFICULTY, CIRCLE "1". IF WITH A LOT OF DIFFICULTY, CIRCLE "2". IF CANNOT SEE AT ALL, CIRCLE "3". IF DON'T KNOW CIRCLE "8".
YES, SOME 1
YES, A LOT 2
YES, TOTAL 3
DON'T KNOW 8
21) PROBLEM OF HEARING
Does (NAME) have difficulty hearing, even if wearing a hearing aid?
IF NO, CIRCLE "0".
IF YES, PROBE: With some difficulty, with a lot of difficulty, or cannot hear at all?
IF SOME WITH SOME DIFFICULTY, CIRCLE "1". IF WITH A LOT OF DIFFICULTY, CIRCLE "2". IF CANNOT HEAR AT ALL, CIRCLE "3". IF DON'T KNOW CIRCLE "8".
YES, SOME 1
YES, A LOT 2
YES, TOTAL 3
DON'T KNOW 8
22) PROBLEM OF WALKING
Does (NAME) have difficulty walking a kilometre or climbing a flight of steps?
IF NO, CIRCLE "0".
IF YES, PROBE: With some difficulty, with a lot of difficulty, or cannot walk or climb steps at all?
IF SOME WITH SOME DIFFICULTY, CIRCLE "1". IF WITH A LOT OF DIFFICULTY, CIRCLE "2". IF CANNOT WALK OR CLIMB AT ALL, CIRCLE "3". IF DON'T KNOW CIRCLE "8".
YES, SOME 1
YES, A LOT 2
YES, TOTAL 3
DON'T KNOW 8
23) PROBLEM OF VISION
Does (NAME) have difficulty remembering or concentrating?
IF NO, CIRCLE "0".
IF YES, PROBE: With some difficulty, with a lot of difficulty, or cannot remember or concentrate at all?
IF SOME WITH SOME DIFFICULTY, CIRCLE "1". IF WITH A LOT OF DIFFICULTY, CIRCLE "2". IF CANNOT REMEMBER OR CONCENTRATE AT ALL, CIRCLE "3". IF DON'T KNOW CIRCLE "8".
YES, SOME 1
YES, A LOT 2
YES, TOTAL 3
DON'T KNOW 8
24) PROBLEM OF SELF-CARE
Does (NAME) have difficulty with self-care such as washing all over or dressing
IF NO, CIRCLE "0".
IF YES, PROBE: With some difficulty, with a lot of difficulty, or cannot do at all?
IF SOME WITH SOME DIFFICULTY, CIRCLE "1". IF WITH A LOT OF DIFFICULTY, CIRCLE "2". IF CANNOT DO AT ALL, CIRCLE "3". IF DON'T KNOW CIRCLE "8".
YES, SOME 1
YES, A LOT 2
YES, TOTAL 3
DON'T KNOW 8
25) PROBLEM OF COMMUNICATING
Does (NAME) have difficulty communicating in (his/her) usual language? For example, understanding others or other understanding (him/her)?
IF NO, CIRCLE "0".
IF YES, PROBE: With some difficulty, with a lot of difficulty, or cannot communicate at all?
IF SOME WITH SOME DIFFICULTY, CIRCLE "1". IF WITH A LOT OF DIFFICULTY, CIRCLE "2". IF CANNOT COMMUNICATE AT ALL, CIRCLE "3". IF DON'T KNOW CIRCLE "8".
YES, SOME 1
YES, A LOT 2
YES, TOTAL 3
DON'T KNOW 8
GOVERNMENT GRANTS:
26) Does (NAME) receive any social grant, old age grant, or social relief assistance from the government?
NO 2 (GO TO NEXT LINE)
21) What type of government grant does name receive?
SEE CODES BELOW
CODES FOR QUESTION 21: GOVERNMENT GRANTS
02 DISABILITY (18-59; R1500)
03 CHILD SUPPORT (0-17; R350)
04 CARE DEPENDENCY (0-17; R1500)
05 FOSTER CHILD (UNDER AGE 22; R890)
06 WAR VETERAN (60 OR OLDER; R1520)
07 IN-AID AND OLD AGE (60-74; R1850; 75+; R1870)
08 IN-AID AND DISABILITY (18-59; R1850)
09 IN-AID AND WAR VETERAN (60 OR OLDER; R1870)
10 SOCIAL RELIEF OF DISTRESS
98 DON'T KNOW
22) Where is (NAME)'s grant money usually collected?
SEE CODES BELOW
CODES FOR QUESTION 22 GRANT COLLECTION SITES:
02 PROCURATOR
03 POST OFFICE
04 INSTITUTION
05 PAY POINT
06 SUPERMARKET
96 OTHER
TICK HERE IF CONTINUATION SHEET USED ____
TABLE FOR SELECTION OF WOMEN FOR THE HOUSEHOLD RELATIONS QUESTIONS
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 IN COLUMN 9A OF 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 HOUSEHOLD RELATIONS QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9A 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 9A SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN 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.
101) What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOUR 13 (GO TO 106)
PUBLIC/COMMUNAL TAP 14 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
WATER-CARRIER/TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK/WATER VENDOR 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91
102) What is the main source of water used by your household for other purposes such as cooking and handwashing?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOUR 13 (GO TO 106)
PUBLIC/COMMUNAL TAP 14
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
WATER-CARRIER/TANKER TRUCK 61
CART WITH SMALL TANK/WATER VENDOR 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
103) Where is that water source located??
IN OWN YARD/PLOT 2 (GO TO 105)
ELSEWHERE/OUTSIDE YARD 3
104) How long does it take to go there, get water, and come back?
DON'T KNOW ____
105) CHECK 101 AND 102: CODE '14' OR '21' CIRCLED?
NO (GO TO 107)
106) In the past two weeks was the water from this source unavailable for at least one full day?
NO 2
DON'T KNOW 8
107) Do you do anything to the water to make it safer to drink?
YES, SOMETIMES 2
NO 3 (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.
ADD BLEACH/CHLORINE/JIK 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 TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE WITH VENTILATION PIPE BUT NO GAUZE MESH/NETTING 22
PIT LATRINE WITHOUT VENTILATION PIPE 23
CHEMICAL TOILET 41
BUCKET TOILET 51
NO FACILITY/BUSH/FIELD 61 (GO TO 113)
110) Do you share this toilet facility with other households?
NO 2 (GO TO 112)
111) Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
112) Where is this toilet facility located?
IN OWN YARD/PLOT 2
ELSEWHERE/OUTSIDE YARD 3
113) What type of fuel does your household mainly use for cooking?
ELECTRICITY FROM GENERATOR 02
ELECTRICITY FROM OTHER SOURCE 03
SOLAR ENERGY 04
GAS 05
PARAFFIN 06
COAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
114) Is the cooking usually done in the house, in a separate building, or outdoors?
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?
NO 2
116) How many rooms in this household are used for sleeping?
116A) What type of energy/fuel does your household mainly use for heating/warming?
ELECTRICITY FROM GENERATOR 02
ELECTRICITY FROM OTHER SOURCE 03
SOLAR ENERGY 04
GAS 05
PARAFFIN 06
COAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
117) Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (GO TO 121)
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) Cattle?
b) Horses, donkeys, or mules?
c) Goats?
d) Sheep?
e) Pigs?
f) Chickens or other poultry?
120) CHECK 113 AND 116A: CODE '01' CIRCLED IN EITHER?
YES (GO TO 121)
121A) Does your household have electricity that is connected to the mains?
NO 2
121) Does your household have any of the following in working condition:
b) A radio?
c) A television?
d) A landline telephone?
e) A desktop or laptop computer?
f) A refrigerator?
g) A vacuum cleaner or floor polisher?
h) A microwave oven?
i) An electric or gas stove?
j) A WASHING MACHINE
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
122) Does any member of this household own any of the following in working condition:
a) A watch?
b) A cell phone?
c) A bicycle?
d) A motorcycle or motor scooter?
e) An animal-drawn cart?
f) A car, bakkie, van or truck?
g) A boat with a motor?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
124) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?
WEEKLY 2
MONTHLY 3
LESS OFTEN THAN ONCE A MONTH 4
NEVER 5
124A) How is the refuse or rubbish in this household mainly disposed of? PROBE: How often is it removed?
REMOVED BY LOCAL AUTHORITIES/PRIVATE COMPANY LESS THAN ONCE A WEEK 02
REMOVED BY COMMUNITY MEMBERS, CONTRACTED BY THE MUNICIPALITY AT LEAST ONCE A WEEK 03
REMOVED BY COMMUNITY MEMBERS, CONTRACTED BY THE MUNICIPALITY LESS OFTEN THAN ONCE A WEEK 04
REMOVED BY COMMUNITY MEMBERS AT LEAST ONCE A WEEK 05
REMOVED BY COMMUNITY MEMBERS LESS OFTEN THAN ONCE A WEEK 06
COMMUNAL REFUSE DUMP 07
COMMUNAL CONTAINER/CENTRAL COLLECTION POINT 08
OWN REFUSE DUMP 09
OWN REFUSE BURNED 10
124B) Do you know where you can get forms to apply for a government grant such as a child or old-age grant?
NO 2 (GO TO 124D)
124C) Where can you obtain forms?
RECORD ALL MENTIONED.
BANK B
MAGISTRATE'S COURT C
DEPARTMENT OF WELFARE/SOCIAL DEVELOPMENT OFFICE D
PAY POINT E
OTHER (SPECIFY) __________ X
DON'T KNOW/UNSURE Z
124D) In the past 12 months, did any adult (18 years and above) in this household go hungry because there wasn't enough food?
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5
NOT APPLICABLE/NO ADULTS IN HOUSEHOLD 6
124E) In the past 12 months, did any child (17 years or younger) in this household go hungry because there wasn't enough food?
SELDOM 2
SOMETIMES 3
OFTEN 4
ALWAYS 5
NOT APPLICABLE/NO CHILDREN IN HOUSEHOLD 6
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, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (GO TO 141A)
NOT OBSERVED, NO PERMISSION TO SEE 4 (GO TO 141A)
NOT OBSERVED, OTHER REASON 5 (GO TO 141A)
140) OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.
WATER IS NOT AVAILABLE 2
141) OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT. RECORD OBSERVATION.
ASH, MUD, SAND B
NONE Y
141A) OBSERVE TYPE OF DWELLING. RECORD OBSERVATION.
TRADITIONAL DWELLING/HUT STRUCTURE MADE OF TRADITIONAL MATERIALS 02
FLAT OR APARTMENT IN BLOCK OF FLATS 03
CLUSTER HOUSE IN COMPLEX 04
TOWN HOUSE/SEMI-DETACHED HOUSE IN COMPLEX 05
SEMI-DETACHED HOUSE 06
DWELLING/HOUSE/FLAT/ROOM IN BACKYARD 07
INFORMAL DWELLING/SHACK IN BACKYARD 08
INFORMAL DWELLING/SHACK NOT IN BACKYARD (E.G., IN AN INFORMAL/SQUATTER SETTLEMENT OR ON FARM) 09
ROOM/FLATLET ON A PROPERTY OR LARGER DWELLING/SERVANTS' QUARTERS/GRANNY FLAT 10
CARAVAN OR TENT 11
OTHER (SPECIFY) __________ 96
142) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.
DUNG 12
VINYL/ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
143) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCHING/GRASS 12
MUD/SOD 13
WATTLE AND DAUB 22
MUD WITH CEMENT MIX 23
BRICKS 24
WOOD PLANKS 25
CARDBOARD 26
WOOD 32
ASBESTOS 33
TILES 34
CEMENT 35
144) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
DIRT/MUD 13
WATTLE AND DAUB 22
STONE WITH MUD 23
MUD WITH CEMENT MIX 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LINE/CEMENT 32
BRICKS 33
CEMENT BLOCK/CONCRETE 34
WOOD PLANKS 36
CORRUGATED IRON/ZINC 37
144A) CHECK COVER PAGE: HOUSEHOLD SELECTED FOR SALT COLLECTION?
NO (GO TO 146)
145) We would like to check whether the salt used in your household is adequately iodised. May I have a sample of the salt used to cook meals in your household?
RECORD BAR CODE NUMBER FROM FIRST BAR CODE LABEL IN BOXES. PLACE THE 1ST BAR CODE LABEL ON THE SALT SAMPLE AND 2ND ON THE TRANSMITTAL FORM.
NO SALT IN HOUSEHOLD 99994
REFUSED 99995
OTHER 99996
MINUTES ____
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ANY OTHER COMMENTS: ____
SUPERVISOR'S OBSERVATIONS: ____