IDENTIFICATION
LOCALITY NAME:
NAME OF HOUSEHOLD HEAD:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
HOUSEHOLD SELECTED FOR FEMALE GENITAL MUTILATION AND DOMESTIC VIOLENCE?
NO 2
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
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*
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S NUMBER
RESULT*
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
02 AMHARIC
03 TIGRIGNA
04 OROMIYA
05 LANGUAGE 5
06 LANGUAGE 6
02 AMHARIC
03 TIGRIGNA
04 OROMIYA
05 LANGUAGE 5
06 LANGUAGE 6
02 AMHARIC
03 TIGRIGNA
04 OROMIYA
05 LANGUAGE 5
06 LANGUAGE 6
NO 2
Hello. My name is ___. I am working with Central Statistical Agency (CSA). We are conducting a survey about health and other topics all over Ethiopia. The information we collect will help the government to place 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 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. 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 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 DOES NOT AGREE TO BE INTERVIEWED 2 (GO TO END)
MINUTES ___
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?
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?
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/STEPCHILD
11 NOT RELATED
98 DON'T KNOW
4. SEX: Is (NAME) male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
IF 95 OR MORE, RECORD '95'.
8. MARITAL STATUS: What is (NAME)'s current marital status?
2 DIVORCED/SEPARATED
3 WIDOWED
4 NEVER-MARRIED AND NEVER LIVED TOGETHER
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: SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
12. Is (NAME)'s natural mother alive?
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'.
14. Is (NAME)'s natural father alive?
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'.
IF AGE 5 YEARS OR OLDER: EVER ATTENDED SCHOOL
16. Has (NAME) ever attended school?
NO 2 (GO TO NEXT LINE)
17. What is the highest level of school (NAME) has attended? What is the highest grade/number of years (NAME) completed at that level?
1 PRIMARY
2 SECONDARY
3 TECHNICAL/VOCATIONAL
4 HIGHER
8 DON'T KNOW
98 DON'T KNOW
IF AGE 5-24 YEARS: CURRENT/RECENT SCHOOL ATTENDANCE
18. Did (NAME) attend school at any time during the (2015-2016) school year?
NO 2 (GO TO NEXT LINE)
19. During (this/that) school year, what level and grade (is/was) (NAME) attending?
1 PRIMARY
2 SECONDARY
3 TECHNICAL/VOCATIONAL
4 HIGHER
8 DON'T KNOW
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 woreda or kebele?
2 REGISTERED
3 NEITHER
8 DON'T KNOW
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14 (GO TO 103)
UNPROTECTED WELL 32 (GO TO 103)
UNPROTECTED SPRING 42 (GO TO 103)
TANKER TRUCK (BOTI) 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 handwashing?
PIPED TO YARD/PLOT 12 (GO TO 106)
PIPED TO NEIGHBOR 13 (GO TO 106)
PUBLIC TAP/STANDPIPE 14
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK (BOTI) 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 YARD/PLOT 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
104A. Who usually goes to this source to fetch the water for your household?
ADULT 2
FEMALE CHILD UNDER 15 YEARS OLD 3
MALE CHILD UNDER 15 YEARS OLD 4
OTHER (SPECIFY) 96
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 not available 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?
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.
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 king 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 SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (GO TO 113)
OTHER (SPECIFY) 96
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 3
113. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP 09
ANIMAL DUNG 10
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 116)
OTHER (SPECIFY) 96
114. Is the cooing 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?
117. Does this household own any livestock, herds, other farm animals, or poultry?
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'.
119. Does any member of this household own any agricultural land?
NO 2 (GO TO 121)
120. How many hectares of agricultural land do members of this household own?
IF 95 ORE MORE, CIRCLE '950'.
95 OR MORE HECTARES 950
DON'T KNOW 998
121. Does your household have:
NO 2
NO 2
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:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
123. Does any member of this household have a bank account?
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
ADDITIONAL HOUSEHOLD CHARACTERISTICS
139. We would like to learn about the places that household 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 142)
NOT OBSERVED, NO PERMISSION TO SEE 4 (GO TO 142)
NOT OBSERVED, OTHER REASON 5 (GO TO 142)
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 AT THE PLACE FOR HANDWASHING.
RECORD OBSERVATION.
ASH, MUD, SAND B
NONE C
142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS/PLASTIC TILE 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/MUD 12
SOD 13
REED/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
CALAMINE/CEMENT FIBER/ASBESTOS 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
CANE/PALM/TRUNKS/BAMBOO/REED 12
DIRT 13
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
145. I would like to check whether the salt used in your household is iodized. May I have sample of the salt used to cook meals in your household?
TEST SALT FOR IODINE.
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) 6
146. In the last 12 months, was nay child or adult OF YOUR HOUSEHOLD killed or injured in any incident with injuries severe enough that for at least one day they could not carry out their normal activities?
NO 2 (GO TO NEXT SECTION)
147. What is the name of the person(s) injured or killed?
ENTER THE NAME OF EACH PERSON INJURED OR KILLED IN QUESTION 148.
IF THERE ARE MORE THAN TWO PEOPLE, USE AN ADDITIONAL QUESTIONNAIRE.
149. Could you tell me in what type of accident (NAME) was injured or killed?
VIOLENCE/ASSAULT 02 (GO TO 151)
FIRE/BURNING 03 (GO TO 151)
ANIMAL BITE 04 (GO TO 151)
ACCIDENTAL FALL 05 (GO TO 151)
DROWNING 06 (GO TO 151)
POISONING 07 (GO TO 151)
KICKED BY CATTLE 08 (GO TO 151)
FALL FROM TREE/BUILDING/ANIMAL BACK 09 (GO TO 151)
OTHER (SPECIFY) 96 (GO TO 151)
DON'T KNOW 98 (GO TO 151)
150. Can you tell me the type of road accident (NAME) was injured or killed?
ROAD ACCIDENT OCCUPANT 2
PEDESTRIAN 3
ROAD ACCIDENT BICYCLE 4
MOTORIZED TWO WHEELER 5
OTHER (SPECIFY) 96
NO 2 (GO TO 154)
152. For how long did (NAME)'s injury prevent her/him from carrying out her/his normal daily activities?
BETWEEN 8 TO 30 DAYS 2
BETWEEN 2 TO 6 MONTHS 3
LONGER THAN 6 MONTHS 4
DON'T KNOW 8
153. IF ALIVE: RECORD LINE NUMBER FROM COLUMN (1).
RECORD '00' IF PERSON NOT LISTED IN HOUSEHOLD.
154. Was (NAME)'s death due to the accident?
NO 2 (GO TO NEXT COLUMN, IF NO MORE GO TO NEXT SECTION)
155. Was (NAME) male or female?
FEMALE 2
156. How old was (NAME) when he/she died?
TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS
(TO BE ADDED TO THE HOUSEHOLD QUESTIONNAIRE)
CHECK COVER PAGE OF QUESTIONNAIRE: HOUSEHOLD SELECTED FOR FEMALE GENITAL MUTILATION MODULE (FGM) AND DOMESTIC VIOLENCE
NO (GO TO 157)
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 01, 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.
HH LINE NUMBER OF SELECTED WOMAN ___
MINUTES ___
TO BE FILLED IN AFTER COMPLETING INTERVIEW