IDENTIFICATION

PLACE NAME

CLUSTER NUMBER

NAME OF HEAD OF HOUSEHOLD

HOUSEHOLD NUMBER

ISLAND/REGION

PREFECTURE AND MUNICIPALITY

URBAN/RURAL (URBAN=1, RURAL=2)

MILIEU

HOUSEHOLD SELECTED FOR MAN'S SURVEY? (YES=1, NO=2)

INTERVIEWER VISITS
1 2 3
DATE

INTERVIEWER'S NAME
RESULT

RESULT CODES:

NEXT VISIT
DATE
TIME

FINAL VISIT
DAY
MONTH
YEAR 2012
NAME
RESULT

TOTAL NO. OF VISITS

TOTAL PERSONS IN HOUSEHOLD

TOTAL ELIGIBLE WOMEN

TOTAL ELIGIBLE MEN

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE

LANGUAGE OF INTERVIEW:

INTERPRETER(YES=1, NO=2)

SUPERVISOR
NAME
DATE

FIELD EDITOR
NAME
DATE

OFFICE EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is ___. I am working with the Office of Statistics and Planning. We are conducting a survey about health all over Comoros. 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 15 to 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 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?

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 5-20 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) In addition, are there any other people who many 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 the household?

CODING:

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 15-49.

10) CIRCLE LINE NUMBER OF ALL MEN 15-59.

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

TICK HERE IF CONTINUATION SHEET USED___

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.

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

15) Does (NAME)'s natural father 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?

CODING:

What is the highest grade (NAME) completed at that level?

CODING:

IF AGE 3-24 YEARS:

CURRENT/RECENT SCHOOL ATTENDANCE:

18) Did (NAME) attend school at any time during the (2011-2012) school year?

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

SEE CODES:

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?

WORK OF CHILDREN AGE 5-14 YEARS:

21) CHECK COLUMN 7: RECORD THE NUMBER OF CHILDREN BETWEEN 5 AND 14 LIVING IN THIS HOUSEHOLD:

21A) CHECK 21:

21B) LINE NUMBER

LIST OF CHILDREN BETWEEN 5 AND 14 YEARS OLD:

CHECK COLUMN 7 OF THE HOUSEHOLD SCHEDULE: RECORD THE NAMES AND LINE NUMBERS OF ALL THE CHILDREN AGE 5 TO 14 IN THE ORDER OF THE HOUSEHOLD SCHEDULE.

21C)

Now I would like to ask you some questions on the type of work that children in your household did last week.

21D) Over the course of the last week, did (NAME) do any work for anyone who is not a member of this household?

IF YES: Was he/she paid in cash or in kind?

21E) IF YES: Since the last (DAY OF THE WEEK OF THE INTERVIEW), approximately how many hours did he/she work for someone who is not a member of this household?

IF MORE THAN ONE JOB, ADD UP ALL THE WORK HOURS.

21F) In the last week, did (NAME) go get water or wood for the household?

21G) IF YES: Approximately how many hours did he/she spend getting water or wood for the household last week?

IF MORE THAN ONCE, ADD THE TOTAL NUMBER OF HOURS.

21H) In the last week, did (NAME) do paid or unpaid work in family fields or in a family business, or did he/she sell merchandise in the street?

21I) IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing work for his/her family or him/herself?

21J) In the last week, did (NAME) do any household chores, such as shopping, cleaning, clothes washing, cooking, or taking care of children, old people, or sick people?

21K) IF YES: Since last (DAY OF THE WEEK), approximately how many hours did he/she spend doing these household chores?

IF MORE THAN ONE CHORE, ADD THE TOTAL NUMBER OF HOURS.

HOUSEHOLD CHARACTERISTICS

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

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

103) Where is the water source located?

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

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? Anything else?

RECORD ALL MENTIONED.

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

FLUSH OR POUR FLUSH TOILET

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

109) How many households use this toilet facility?

110) Does your household have:

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?

CODES 2-6 (GO TO 114).

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 ROOF: RECORD OBSERVATION

116) MAIN MATERIAL OF THE EXTERIOR WALLS: RECORD OBSERVATION

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

118) Does any member of your household own:

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

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

IF 95 OR MORE, CIRCLE 950.

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

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

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

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 THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(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 with 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.

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

135) Who slept under the mosquito net last night?

RECORD THE PERSON'S LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

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 WATER AT THE PLACE FOR HANDWASHING.

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

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

141) SELECTION TABLE FOR HOUSEHOLD WOMEN FOR "DOMESTIC VIOLENCE"

THIS SECTION IS APPLIED TO ALL THE HOUSEHOLDS IN THE SAMPLE, HOWEVER ONLY ONE WOMAN WILL BE SURVEYED PER HOUSEHOLD FOR THIS SECTION: THE TABLE THAT FOLLOWS WILL HELP YOU RANDOMLY SELECT THIS WOMAN FROM THE HOUSEHOLD.

TAKE THE LAST DIGIT FROM THE SERIES NUMBER OF THE HOUSEHOLD QUESTIONNAIRE ON THE COVER PAGE. THIS IS THE LINE 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 LINE AND THE COLUMN SELECTED TO THE BOX WHERE THEY MEET AND CIRCLE THE NUMBER IN THE BOX. THIS IS THE ORDER NUMBER OF THE WOMAN SELECTED TO RESPOND TO THE QUESTIONS ON DOMESTIC VIOLENCE BASED ON THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. RECORD THE NAME AND LINE NUMBER OF THE SELECTED WOMEN IN THE SPACE BELOW THE TABLE.

EXAMPLE: THE SERIES NUMBER OF THE HOUSEHOLD QUESTIONNAIRE IS '716' AND THE COLUMN 9 IN THE HOUSEHOLD SCHEDULE SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). GIVEN THAT THE LAST DIGIT FROM THE SERIES NUMBER OF THE HOUSEHOLD IS '6', GO TO LINE '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE LINE AND THE COLUMN TO FIND THE NUMBER OF THE BOX WHERE THEY CROSS (2); CIRCLE THIS NUMBER. NEXT GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND ELIGIBLE WOMAN FOR THE INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). RECORD HER NAME AND LINE NUMBER IN THE SPACE PROVIDED UNDER THE TABLE.

[LINE]: LAST DIGIT OF SERIES NUMBER FROM THE HOUSEHOLD QUESTIONNAIRE

[COLUMN]: TOTAL NUMBER OF ELIGIBLE WOMEN AGE 15-49 IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE

SECTION 4A. WEIGHT AND HEIGHT FOR CHILDREN AGE 0-5

401) CHECK COLUMN 11 OF THE HOUSEHOLD SCHEDULE. RECORD THE LINE NUMBER AND AGE FOR ALL ELIGIBLE CHILDREN 0-5 YEARS (UNDER 6 YEARS) IN Q 402. IF MORE THAN 6 CHILDREN, USE ADDITIONAL QUESTIONNAIRE(S). THE FINAL MEASUREMENTS FOR WEIGHT AND HEIGHT MUST BE RECORDED IN 405 AND 406.

402) LINE NUMBER FROM COLUMN 11 AND NAME FROM COLUMN 2:

403) What is (NAME'S) birth date?

IF MOTHER INTERVIEWED, COPY MONTH AND YEAR OF CHILD'S BIRTH FROM BIRTH HISTORY AND ASK DAY; IF MOTHER NOT INTERVIEWED, ASK: WHAT IS (NAME)'S BIRTH DATE?

404) CHECK 203: CHILD BORN IN JANUARY 2007 OR LATER?

405) WEIGHT IN KILOGRAMS

406) HEIGHT IN CENTIMETERS

407) Measured lying down or standing up?

408) Presence of bilateral edema in feet?

409) GO BACK TO 402 IN NEXT COLUMN OF THIS QUESTIONNAIRE OR TO THE TABLE BELOW, IN THE FIRST COLUMN FOR CHILDREN AGE 4-6. IF THERE ARE NO MORE CHILDREN, GO TO 501.

WEIGHT AND HEIGHT FOR WOMEN 15-49

501) CHECK COLUMN 9. RECORD THE LINE NUMBER AND NAME FOR ALL ELIGIBLE WOMEN 15-49 IN QUESTION 501. IF THERE ARE MORE THAN 6 WOMEN, USE AN ADDITIONAL QUESTIONNAIRE.
THE FINAL HEIGHT AND WEIGHT RESULT CODE MEASUREMENTS MUST BE RECORDED IN 503 AND 504.

502) LINE NUMBER FROM COLUMN 9 AND NAME FROM COLUMN 2:

503) WEIGHT IN KILOGRAMS

504) HEIGHT IN CENTIMETERS

505) GO BACK TO Q. 502 IN NEXT COLUMN OF THIS QUESTIONNAIRE FOR THE NEXT WOMAN. IF THERE ARE MORE THAN THREE WOMEN, USE THE TABLE THAT FOLLOWS. IF NO MORE WOMEN, END THE HOUSEHOLD INTERVIEW.