ZIMBABWE

IDENTIFICATION

PLACE NAME:

NAME OF HOUSEHOLD HEAD:

CLUSTER NUMBER:

HOUSEHOLD NUMBER:

INTERVIEWER VISITS

FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT

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

LANGUAGE OF INTERVIEW

TRANSLATOR USED?

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 ___

100. RECORD THE TIME.

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?

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

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

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

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

5. RESIDENCE: Does (NAME) usually live here?

6. Did (NAME) stay here last night?

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

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

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?

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?

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?

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

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

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.

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 hand washing?

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' OR '21'

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.

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

IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

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 these following animals does this household own?

IF NONE, RECORD '00'.

IF 95 OR MORE, RECORD '95'.

IF UNKNOWN, RECORD '98'.

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

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

IF 95 OR MORE, RECORD '950'.

121. Does your household have:

122. Does any member of this household own:

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, months, less often than once a month, or never?

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

126. Who sprayed the dwelling?

127. Does your household have any mosquito nets?

128. How many mosquito nets does your household have?

IF 7 OR MORE NETS, RECORD '7'.

MOSQUITO NETS

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

IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRES.

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

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

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.

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

133. Where did you get the net?

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

)

135. Who slept under this mosquito net last night?

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

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?

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

RECORD OBSERVATION.

141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HAND WASHING.

RECORD OBSERVATION.

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

RECORD OBSERVATION.

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

RECORD OBSERVATION.

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

RECORD OBSERVATION.

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.

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:

EDITORS OBSERVATIONS: