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DEMOGRAPHIC AND HEALTH SURVEY - 2015 ZIMBABWE - HOUSEHOLD QUESTIONNAIRE (ENGLISH)

ZIMBABWE

IDENTIFICATION

PLACE NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*

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)

SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*

NEXT VISIT
DATE
TIME

THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*

FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S NUMBER
RESULT*

TOTAL NUMBER OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN

TOTAL ELIGIBLE MEN

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF QUESTIONNAIRE

01 ENGLISH
02 NDEBELE
03 SHONA

LANGUAGE OF INTERVIEW

01 ENGLISH
02 NDEBELE
03 SHONA

TRANSLATOR USED?

YES 1
NO 2

SUPERVISOR
NAME
NUMBER

OFFICE EDITOR
NAME
NUMBER

KEYED BY
NAME
NUMBER

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the Central Statistical Office/ZIMSTAT. We are conducting a survey about health and other topics all over Zimbabwe. The information we collect will help the government to plan health services. Your household was randomly selected for the survey. I would like to ask you some questions about your household. The questions usually take about 15-20 minutes. All of the answers you give will be confidential and will not be shared with anyone other than members of our survey team. Participation in the survey is voluntary. It's up to you if you want 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?
Do you agree to participate in the survey? May I begin the interview now?

SIGNATURE OF INTERVIEWER CONFIRMING CONSENT STATEMENT HAS BEEN READ TO THE RESPONDENT ___
DATE ___

RESPONDENT AGREES TO BE INTERVIEWED 1 (GO TO 100)
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (GO TO END)

100. RECORD THE TIME.

HOURS ___
MINUTE ___

HOUSEHOLD SCHEDULE

1. LINE NUMBER

___

2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.

AFTER LISTING THE NAMES AND RECORDING THE RELATIONSHIP AND SEX FOR EACH PERSON. ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE.

THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-20 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?

YES (ADD TO TABLE)
NO

2B. Are there any other people who may not be members of your family, such as domestic servants, or friends who usually live here?

YES (ADD TO TABLE)
NO

2C. Are there any guests or temporary visitors saying 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?

01 HEAD
02 WIFE OR HUSBAND
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/FOSTER/STEP CHILD
11 NOT RELATED
98 DON'T KNOW

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

MALE 1
FEMALE 2

5. RESIDENCE: 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'.

IN YEARS ___

IF AGE 12 OR OLDER
8. MARITAL STATUS: What is (NAME)'s current marital status?

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

ELIGIBILITY
9. CIRCLED LINE NUMBER OF ALL WOMEN AGE 15-49

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

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

11A. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 6-14

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?
RECORD MOTHER'S LINE NUMBER.
IF NO, RECORD '00'.

___

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?
RECORD FATHER'S LINE NUMBER.
IF NO, RECORD '00'.

___

IF AGE 3 YEARS OR OLDER: EVER ATTENDED SCHOOL
16. Has (NAME) ever attended school?

YES 1
NO 2 (GO TO 20)

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

LEVEL
0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW
GRADE
00 LESS THAN 1 YEAR COMPLETED (USE '00' FOR QUESTION 17 ONLY. THIS CODE IS NOT ALLOWED FOR QUESTION 19)
98 DON'T KNOW

IF AGE 3-24 YEARS: CURRENT/RECENT SCHOOL ATTENDANCE
18. Did (NAME) attend school at any time during the 2015 school year?

YES 1
NO 2 (GO TO 20)

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

LEVEL
0 PRESCHOOL
1 PRIMARY
2 SECONDARY
3 HIGHER
8 DON'T KNOW
GRADE
00 LESS THAN 1 YEAR COMPLETED (USE '00' FOR QUESTION 17 ONLY. THIS CODE IS NOT ALLOWED FOR QUESTION 19)
98 DON'T KNOW

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 Births and Deaths Registry?

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

SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE 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 (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.

LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ___
AL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN HOUSEHOLD SCHEDULE COLUMN ___

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?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD OR PLOT 12 (GO TO 106)
PIPED TO NEIGHBORHOOD 13 (GO TO 106)
PIPED INTO DWELLING FROM BOREHOLE 14 (GO TO 106)
PUBLIC TAP OR STANDPIPE 15 (GO TO 103)
TUBE WELL OR BOREHOLE 21 (GO TO 103)
DUG WELL
PROTECTED WELL 31 (GO TO 103)
UNPROTECTED 32 (GO TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 103)
TANKER TRUCK 61 (GO TO 103)
CART WITH SMALL TANK 71 (GO TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (GO TO 103)
BOTTLED WATER 91
OTHER (SPECIFY) 96 (GO TO 103)

102. What is the main source of water used by your household for other purposes such as cooking and hand washing?

PIPED WATER
PIPED INTO DWELLING 11 (GO TO 106)
PIPED TO YARD OR PLOT 12 (GO TO 106)
PIPED TO NEIGHBORHOOD 13 (GO TO 106)
PIPED INTO DWELLING FROM BOREHOLE 14 (GO TO 106)
PUBLIC TAP OR STANDPIPE 15
TUBE WELL OR BOREHOLE 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED 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 OR 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: CODE '14' OR '21'

YES (GO TO 106)
NO (GO TO 107)

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

YES 1
NO 2
DON'T KNOW 8

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

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

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

RECORD ALL MENTIONED.

BOIL A
ADD BLEACH OR CHLORINE B
STRAIN THROUGH A CLOTH C
USE WATER FILTER (CERAMIC/SAN/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
BUCKET TOILET 31
NO FACILITY/BUSH/FIELD 41 (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?

NUMBER 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
LP GAS 02
NATURAL GAS 03
BIOGAS 04
PARAFFIN/KEROSENE 05
COAL, LIGNIT 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
ANIMAL DUNG 10
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)
OUTDOOR 3 (GO TO 116)
OTHER (SPECIFY) 6 (GO TO 116)

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

YES 1
NO 2

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

ROOMS ___

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

YES 1
NO 2 (GO TO 119)

118. How many of these 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. Chickens or other poultry?
___
f. Rabbits?
___
g. Pigs?
___

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

YES 1
NO 2 (GO TO 121)

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

IF 95 OR MORE, RECORD '950'.

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

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. Battery or generator for power?
YES 1
NO 2
h. Solar panel?
YES 1
NO 2
i. Pushing tray?
YES 1
NO 2
j. Axe/hoe?
YES 1
NO 2
k. Chair/stool?
YES 1
NO 2
l. Plow?
YES 1
NO 2
m. Wardrobe?
YES 1
NO 2
n. Satellite dish/decoder?
YES 1
NO 2
o. Washing machine?
YES 1
NO 2
p. Borehole?
YES 1
NO 2
q. Mattress?
YES 1
NO 2
r. Bed?
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

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

YES 1
NO 2

124. How often does anyone smoke inside your house? Would you say daily, weekly, months, less often than once a month, or never?

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

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

MOSQUITO NETS

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

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRES.

OBSERVED 1
NOT OBSERVED 2

130. How many months ago did your household et the mosquito net?

IF LESS THAN ONE MONTHS 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)
OLYSET 11 (GO TO 134)
PERMANE 12 (GO TO 134)
OTHER/DON'T KNOW BRAND 16 (GO TO 134)
OTHER TYPE 96
DON'T KNOW TYPE 98

132. Did you get the net through a school distribution campaign, during an antenatal care visit, or during an immunization visit?

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

133. Where did you get the net?

GOVERNMENT HEALTH FACILITY 01
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
MISSION HOSPITAL 06
SCHOOL 07
OTHER 08
DON'T KNOW 09

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

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

)

135. Who slept under this mosquito net last night?

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

NAME ___
LINE NUMBER ___

136. 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
NOT OBSERVED, OTHER REASON 5

140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HAND WASHING.

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 HAND WASHING.

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
FINISHED FLOOR
PARQUET OR POLISHED WOOD 31
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) 96

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

RECORD OBSERVATION.

NATURAL ROOFING
NO ROOF 11
THATCH/PALM LEAF 12
RUDIMENTARY ROOFING
RUSTIC MAT 21
PALM/BAMBOO 22
WOOD PLANK 23
CARDBOARD 24
FINISHED ROOFING
METAL 31
WOOD 32
ASBESTOS 33
TILES 34
CEMENT 35
ROOFING SHINGLE 36
OTHER (SPECIFY) 96

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

RECORD OBSERVATION.

NATURAL WALLS
NO WALLS 11
CANE/PALM/TRUNK 12
MUD 13
RUDIMENTARY WALLS
STONE WITH MUD 21
PLYWOOD 22
CARDBOARD 23
REUSED WOOD 24
FINISHED WALLS
CEMENT 31
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCK 34
WOOD PLANKS/SHINGLES 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. RECORD THE TIME.

HOURS ___
MINUTE ___

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS:

EDITORS OBSERVATIONS: