IDENTIFICATION

COUNTY ____

DISTRICT ____

LOCATION/TOWN ____

SUBLOCATION ____

NASSEP CLUSTER NUMBER ____

KDHS CLUSTER NUMBER ____

HOUSEHOLD NUMBER ____

NAME OF HOUSEHOLD HEAD ____

IS HOUSEHOLD SELECTED FOR WOMEN'S SECTION 14?

INTERVIEWER VISITS

FIRST VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

SECOND VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

THIRD VISIT
DATE ____
INTERVIEWER'S NAME ____
RESULT*

NEXT VISIT
DATE ____
TIME ____

FINAL VISIT
DAY ____
MONTH ____
YEAR ____
INT. NUMBER ____
RESULT ____

TOTAL NUMBER OF VISITS ____

*RESULT CODES

LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE___

TOTAL PERSONS IN HOUSEHOLD___

TOTAL ELIGIBLE WOMEN___

TOTAL ELIGIBLE MEN___

LANGUAGE OF QUESTIONNAIRE 17/ENGLISH

LANGUAGE OF INTERVIEW___

NATIVE LANGUAGE OF RESPONDENT___

TRANSLATOR USED

SUPERVISOR
NAME ____

FIELD EDITOR
NAME ____

OFFICE EDITOR ____

KEYED BY ____

INTRODUCTION AND CONSENT

Hello. My name is _______________________________________. I am working with the Kenya National Bureau of Statistics. We are conducting a survey about health all over Kenya. 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 30 to 60 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 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: ____

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 5-20A FOR EACH PERSON.

2A) Just to make sure that I have a complete listing: are there any other persons 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?

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

SEE CODES BELOW.

CODES FOR Q. 3: RELATIONSHIP TO HEAD OF HOUSEHOLD

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

RESIDENCE:

5) 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 15 OR OLDER:

8) MARITAL STATUS:
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 15-54

11) CIRCLE LINE NUMBER OF ALL CHILDREN 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? IF YES: What is her name? RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.

IF AGE 0-17 YEARS:

SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS:

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 YES: What is his name? 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? SEE CODES BELOW.
What is the highest grade (NAME) completed at that level? SEE CODES BELOW.

CODES FOR Qs. 17, 19, AND 19B: EDUCATION

IF AGE 3-24 YEARS :

CURRENT/RECENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school at any time during the 2014 school year?

19) During the 2014 school year, what level and grade [is/was] (NAME) attending? SEE CODES BELOW.

19A) Did (NAME) attend school at any time during the 2013 school year?

19B) During the 2013 school year, what level and grade did (NAME) attend? SEE CODES BELOW.

IF AGE 0-4 YEARS:

BIRTH REGISTRATION:

20) Has (NAME) ever been registered with the civil authority?

IF YES: With a birth certificate?

20A) Why was (NAME) never registered?

SELECTION OF WOMEN FOR SECTION 14: DOMESTIC VIOLENCE QUESTIONS

101A) ONLY ONE INDIVIDUAL (ONE WOMAN OR ONE MAN SHOULD BE SELECTED FOR DOMESTIC VIOLENCE QUESTIONS)

CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR WOMEN'S SECTION 14?

HOW TO USE THE TABLE FOR SELECTION OF A RESPONDENT:

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 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.

SELECTION OF MEN FOR SECTION 10: DOMESTIC VIOLENCE QUESTIONS

101B) ONLY ONE INDIVIDUAL (ONE WOMAN OR ONE MAN SHOULD BE SELECTED FOR DOMESTIC VIOLENCE QUESTIONS)

CHECK COVER PAGE:
HOUSEHOLD SELECTED FOR WOMEN'S SECTION 14?

HOW TO USE THE TABLE FOR SELECTION OF A RESPONDENT:

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 MEN (COLUMN 10) 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 MAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE MEN IN COLUMN 10 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED MAN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 10 SHOWS THAT THERE ARE THREE ELIGIBLE MEN AGE 15-54 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 MEN 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 MAN WHO IS ELIGIBLE FOR THE MAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HIS NAME AND LINE NUMBER IN THE SPACE BELOW THE TABLE.

HOUSEHOLD CHARACTERISTICS

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

103) Where is that water source located?

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

IF 995 OR MORE, ENTER '995'.

104A) Who usually goes to this source to fetch the water for your household?

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

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

RECORD ALL MENTIONED.

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

108) Do you share this toilet facility with other households?

109) How many households use this toilet facility?

110) Does your household have:

A) Electricity?

B) A radio?

C) A television?

D) A mobile telephone?

E) A non-mobile telephone?

F) A refrigerator?

G) A solar panel?

H) A table?

I) A chair?

J) A sofa?

K) A bed?

L) A cupboard?

M) A clock?

N) A microwave oven?

O) A DVD player?

P) A cassette or CD player?

110A) Does this household receive a cash transfer or any social assistance from the government?

110B) For what reason does the household receive a cash transfer or social assistance?

Any other reason?

RECORD ALL MENTIONED

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

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

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

114) MAIN MATERIAL OF THE FLOOR. RECORD OBSERVATION.

115) MAIN MATERIAL OF THE ROOF. RECORD OBSERVATION.

116) MAIN MATERIAL OF EXTERNAL WALLS. RECORD OBSERVATION.

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

118) Does any member of this household own:

A) A watch?

B) A bicycle?

C) A motorcycle or motor scooter?

D) An animal-drawn cart?

E) A car or truck?

F) A boat with a motor?

118A) Does you household own this structure (house, flat, shack), do you pay rent, or do you live here without paying rent?

118B) Does your household own the land on which the structure (house, flat, shack) sits?

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

120) How many acres or hectares of agricultural land do members of this household own?

ACRES/HECTARES: IF 995 OR MORE, RECORD '995.0' IN APPROPRIATE BOX
PLOT SIZE (SQ) FT: IF 99995 OR MORE, RECORD '99995.0' IN APPROPRIATE BOX

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

122) How many of the following animals does this household own?
IF NONE, ENTER '00'. IF 95 OR MORE, ENTER '95'. IF UNKNOWN, ENTER '98'.

A) Local cattle (indigenous)?

B) Exotic/grade cattle?

C) Horses, donkeys, or camels?

D) Goats?

E) Sheep?

F) Chickens?

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

123A) In the past 7 days were there days when your household did not have enough food or money to buy food?

123B) How many days did your household have to:

A) Rely on less preferred, less expensive food?

B) Rely on borrowed food from friends or relatives?

C) Reduce the number of meals eaten per day?

D) Reduce the portion size of meals?

E) Reduce the quantities eaten by adults in order for small children to eat?

123C) How often does anyone smoke inside your house?

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

124A) How many months ago did someone spray your dwelling against mosquitos?

125) Who sprayed the dwelling?

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

127) How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

128) ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRES(S).

129) How many months ago did your household get the mosquito net?

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

130) OBSERVE OR ASK THE BRAND/TYPE OF MOSQUITO NET.

IF BRAND IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.

131) When you got the net, was it already treated as an insecticide to kill or repel mosquitoes?

132) Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?

133) How many months ago was the net last soaked or dipped?

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

133A) The last time the net was treated, was a liquid from a packet like this added to the treatment solution?

SHOW SACHET FOR K-O TAB 1-2-3 BINDING AGENTS.

133B) The last time the net was treated, was it treated as part of a net retreatment campaign?

135) Who slept under this mosquito net last night?

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

136) GO BACK TO 128 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 137.

137) Please show me where members of your household most often wash their hands.

138) OBSERVATION ONLY. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

139) OBSERVATION ONLY: OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT.

139A) Do members of your household wash their hands with soap?

139B) When do they wash their hands?

Any other time?

RECORD ALL MENTIONED.

HOUSEHOLD FOOD CONSUMPTION

139C-A) Now, I would like to talk to you about the food consumed in your household during the past 7 days. How many days during the past 7 days, did members of your household consume the following food items, prepared or eaten at home?

139C-B) What was the main source of the (NAME OF FOOD ITEM)? SEE SOURCE CODES BELOW.

140) ASK RESPONDENT FOR A TEASPOON OF COOKING SALT. TEST SALT FOR IODINE.

WEIGHT AND HEIGHT MEASUREMENT FOR CHILDREN AGE 0-5

201) CHECK COLUMN 11 IN HOUSEHOLD SCHEDULE.

RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE CHILDREN 0-5 YEARS IN QUESTION 202.

IF MORE THAN SIX CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S).

202) LINE NUMBER FROM COLUMN 11:
NAME FROM COLUMN 2:

203) IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF BIRTH HISTORY AND ASK DAY, IF MOTHER NOT INTERVIEWED, ASK: What is (NAME)'s birth date?

204) CHECK 203: CHILD BORN IN JANUARY 2009 OR LATER?

205) WEIGHT IN KILOGRAMS

206) HEIGHT IN CENTIMETERS

207) MEASURED LYING DOWN OR STANDING UP?

213) GO BACK TO 203 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF THE NEXT PAGE; IF NO MORE CHILDREN, GO TO 214.

WEIGHT AND HEIGHT MEASUREMENT FOR WOMEN AGE 15-49

214) CHECK COLUMN 9 IN HOUSEHOLD SCHEDULE.

RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN IN 215.

IF THERE ARE MORE THAN THREE WOMEN, USE ADDITIONAL QUESTIONNAIRE(S).

215) LINE NUMBER FROM COLUMN 9:
NAME FROM COLUMN 2:

216) WEIGHT IN KILOGRAMS

217) HEIGHT IN CENTIMETERS

242) GO BACK TO 216 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR IN THE FIRST COLUMN OF AN ADDITIONAL QUESTIONNAIRE; IF NO MORE WOMEN, END INTERVIEW