IDENTIFICATION

LOCALITY NAME _______________
NAME OF HOUSEHOLD HEAD _______________
CLUSTER NUMBER _____
HOUSEHOLD NUMBER _____

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

NEXT VISIT:

FINAL VISIT:

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____

TOTAL ELIGIBLE WOMEN _____

TOTAL ELIGIBLE MEN _____

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01

LANGUAGE OF INTERVIEW**:

NATIVE LANGUAGE OF RESPONDENT**:

TRANSLATOR USED

SUPERVISOR
NAME _______________
NUMBER ______________

INTRODUCTION AND CONSENT

Hello. My name is __________________________. I am working with the Ministry of Health in collaboration with Central Statistical Office (CSO). We are conducting a survey about health and other topics all over Zambia. 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 note 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 (GO TO 1)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

(100) RECORD THE TIME.

HOUSEHOLD SCHEDULE

(1) LINE NO.

USUAL RESIDENTS AND VISITORS
(2) 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 RELATIONSHIPS AND SEX FOR EACH PERSON, ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.
THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 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?

(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?

(2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?

RELATIONSHIP TO THE HEAD OF THE HOUSEHOLD

(3) What is the relationship of (NAME) to the head of the household?

SEX

(4) Is (NAME) male or female?

RESIDENCE

(5) Does (NAME) usually live here?

(6) Did (NAME) stay here last night?

AGE

(7) How old is (NAME)?

IF AGE 15 OR OLDER

MARITAL STATUS

(8) What is (NAME)'s current marital status?

ELIGIBILITY

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

(10) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59

(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?

(13) Does (NAME)'s natural mother usually live in this household or was she a guest last night?

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

(15) Does (NAME)'s natural father usually live in this household or was he a guest last night?

IF AGE 2 YEARS OR OLDER

EVER ATTENDED SCHOOL

(16) Has (NAME) ever attended school or a nursery/kindergarten?

(17) What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?

IF AGE 2-24 YEARS

CURRENT/RECENT SCHOOL ATTENDANCE

(18) Did (NAME) attend school or a nursery/kindergarten at any time during the 2018 school year?

(19) During [this/that] school year, what level and grade [is/was] (NAME) attending?

IF AGE 0-4 YEARS

BIRTH REGISTRATION

(20) Does (NAME) have a birth certificate?

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

CLICK HERE IF CONTINUATION SHEET USED _____

SELECTION OF WOMAN FOR THE DOMESTIC VIOLENCE QUESTIONS (PAPER OPTION)

(31) CHECK COL.9 IN THE HOUSEHOLD SCHEDULE AND WRITE THE TOTAL NUMBER OF WOMEN AGE 15-49 YEARS.

(32) CHECK THE NUMBER OF WOMEN AGE 15-49 YEARS IN 31:

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 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 NUMBER IS '16' 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.

LAST DIGIT OF THE HOUSEHOLD NUMBER (ROW)
TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN 9 (COLUMN)

(33) NAME OF SELECTED WOMAN _______________

HH LINE NUMBER OF SELECTED WOMAN _____

HOUSEHOLD CHARACTERISTICS

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

(102) What is the main source of water used by your household for other purposes such as cooking and handwashing?

(103) Where is that water source located?

(104) How long does it take to go there, get water, and come back?

(105) CHECK 101 AND 102: CODE '14' AND '21' CIRCLED?

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

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

(108) What do you usually do to make the water safer to drink?

Anything else?
RECORD ALL MENTIONED.

(108A) How do you store your drinking water?

(109) What kind of toilet facility do members of your household usually use?

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

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

(112) Where is this toilet facility located?

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

(114) Is the cooking usually done in the house, in a separate building, or outdoors?

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

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

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

(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) Traditional cattle?
b) Dairy cattle?
c) Beef cattle?
d) Horses, donkeys, or mules?
e) Goats?
f) Sheep?
g) Chickens?
h) Pigs?
i) Rabbits/Other Poultry?
j) Other Livestock?

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

(120) How much hectares, acres, or lima of agricultural land do members of this household own?

IF 95 OR MORE HECTARES, CIRCLE '950'.
IF 95 OR MORE ACRES, CIRCLE '951'.
IF 95 OR MORE LIMA, CIRCLE '952'.

(121) Does your household have:

a) Electricity?
b) A radio?
c) A television?
d) A computer?
e) A refrigerator?
f) Access to Internet?
g) A bed?
h) A table?
i) A sofa?
j) A washing machine?
k) An air conditioner?
l) A generator?
m) A microwave?
n) A geyser (water heater)?
o) A grain grinder?
p) A plough?
q) A tractor?
r) A hammer mill?

n) GEYSER

o) GRAIN GRINDER

p) PLOUGH

(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?
h) A banana boat?

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

(124) How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less than monthly, or never?

(124A) At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

(124B) Who sprayed the dwelling?

(127) Does your household have any mosquito nets that can be used while sleeping?

(128) How many mosquito nets does your household have?

MOSQUITO NETS

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

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

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

IF LESS THAN ONE MONTH AGO, RECORD '00'. (REPEAT FOR 3 NETS)

(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. (REPEAT FOR 3 NETS)

(134) Did you get the net through a mass distribution campaign, school distribution, during an antenatal care visit, or during an under five visit? (REPEAT FOR 3 NETS)

(135) Where did you get the net? (REPEAT FOR 3 NETS)

(136) Did anyone sleep under this mosquito net last night? (REPEAT FOR 3 NETS)

(137) Who slept under this mosquito net last night?

RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE. (REPEAT FOR 3 NETS)

(138)

GO BACK TO 129 FOR NEXT NET; IF NO MORE NETS, GO TO 139
GO BACK TO 129 FOR NEXT NET; IF NO MORE NETS, GO TO 139
GOT TO 129 IN FIRST COLUMN OF A QUESTIONNAIRE; 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?

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

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

(142) OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.

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

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

(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?

(146) RECORD THE TIME.

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:
_______________________________________________________________