MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
REPUBLIC OF RWANDA
MALARIA AND OTHER PARASITIC DISEASES DIVISION
IDENTIFICATION
PLACE NAME __
NAME OF HOUSEHOLD HEAD __
CLUSTER NUMBER __
HOUSEHOLD NUMBER __
FIRST VISIT
INTERVIEWER'S NAME __
RESULT* __
NEXT VISIT:
TIME __
SECOND VISIT
INTERVIEWER'S NAME __
RESULT* __
NEXT VISIT:
TIME __
THIRD VISIT
INTERVIEWER'S NAME __
RESULT* __
FINAL VISIT
MONTH __
YEAR __
INT. NUMBER __
RESULT __
TOTAL NUMBER OF VISITS __
*RESULT CODES:
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER 9 (SPECIFY) __
TOTAL PERSONS IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __
SUPERVISOR
NAME __
OFFICE EDITOR __
KEYED BY __
Hello. My name is ________________________________. I am working with MOPDD. We are conducting a survey about malaria all over RWANDA. 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 now?
SIGNATURE OF INTERVIEWER: ________________________________ DATE: _________
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)
LINE NO.
(1) __
USUAL RESIDENTS AND VISITORS
(2) 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 5-7 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 are 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
RELATIONSHIP TO HEAD OF HOUSEHOLD
(3) What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD
WIFE OR HUSBAND = 02
SON OR DAUGHTER = 03
SON-IN-LAW OR DAUGHTER-IN-LAW = 04
GRANDCHILD = 05
PARENT = 06
PARENT-IN-LAW = 07
BROTHER OR SISTER = 08
NIECE/NEPHEW BY BLOOD = 09
NIECE/NEPHEW BY MARRIAGE = 10
OTHER RELATIVE = 11
ADOPTED/FOSTER/STEP CHILD = 12
NOT RELATED = 13
DON'T KNOW = 98
SEX
(4) Is (NAME) male or female?
FEMALE 2
RESIDENCE
(5) Does (NAME) usually live here?
NO 2
(6) Did (NAME) stay here last night?
NO 2
AGE IN YEAR
(7) How old is (NAME)?
IF 15 YEARS OR OLDER
MARITAL STATUS
(7A) What is (NAME'S) current marital status?
DIVORCED/SEPARATED = 2
WIDOWED = 3
NEVER-MARRIED AND NEVER LIVED TOGETHER = 4
__
ELIGIBILITY
(8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49 YEARS
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 104)
PUBLIC TAP/STANDPIPE 13
UNPROTECTED WELL 41
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/PONDS/STREAM/CANAL/IRRIGATION CHANNGEL) 81
BOTTLED WATER 91
OTHER 96 (SPECIFY) __
102. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 104)
ELSEWHERE 3
103. How long does it take to go there, get water, and come back?
DON'T KNOW 998
104. What kind of toilet facility do members of your household usually use?
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 14
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 (SKIP TO 107)
OTHER 96 (SPECIFY) __
105. Do you share this toilet facility with other households?
NO 2 (SKIP TO 107)
106. How many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
107. Does your household have:
A radio?
A television?
A mobile phone?
A non-mobile telephone?
A refrigerator?
A computer?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
108. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95
OTHER 96 (SPECIFY) __
109. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
110. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
THATCH/PALM LEAF 12
SOD 13
PALM/BAMBOO 22
WOOD PLANKS 23
CARDBORD 24
WOOD 32
CALAMINE/CEMENT FIBER 33
CERAMIC TILES 35
ROOFING SHINGLES 36
111. MAIN MATERIAL OF THE EXTERIOR WALLS.
RECORD OBSERVATION.
CANE/PALM/TRUNKS 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
112. How many rooms in this household are used for sleeping?
113. Does any member of this household own:
A bicycle?
A motorcycle or motor scooter?
An animal-drawn cart?
A car or truck?
A boat with a motor?
A boat without a motor?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
114. Does any member of this household own any agricultural land?
NO 2 (SKIP TO 116)
115. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE '950'.
95 OR MORE HECTARES 950
DON'T KNOW 998
116. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (SKIP TO 118)
117. How many of the following animals does this household own?
How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MORE, ENTER '95'.
IF UNKOWN, ENTER '98'.
Milk cows?
Bulls?
Goats?
Sheep?
Chickens?
Pigs?
Rabbits?
Horses, donkeys, or mules?
MILK COWS __
BULLS __
GOATS __
SHEEP __
CHICKENS __
PIGS __
RABBITS __
HORSES/DONKEYS/MULES __
118. Does any member of this household have a bank account?
NO 2
119. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?
NO 2 (SKIP TO 121)
DON'T KNOW 8 (SKIP TO 121)
120. Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER X (SPECIFY) __
DON'T KNOW Z
121. Does your household have any mosquito nets that can be used while sleeping?
NO 2 (SKIP TO 133)
122. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
123. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NET #1
NOT OBSERVED 2
124. How many months ago did you get the mosquito net?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
124A. How did you obtain the net?
DURING IMMUNIZATION CAMPAIGN 12
DURING ANC VISIT 13
FROM A COMMUNITY HEALTH WORKER 14
FROM PHARMACY 15
FROM SHOP 16
OTHER 96 (SPECIFY) __
125. 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
OTHER LLIN DK BRAND 16 (SKIP TO 128)
DK BRAND 98
126. Since you got the net, was it ever soaked or dipped in a liquid to kill or repel mosquitoes?
NO 2 (SKIP TO 128)
NOT SURE 8 (SKIP TO 128)
127. How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 24 MONTHS AGO 95
NOT SURE 98
128. OBSERVE CONDITION OF MOSQUITO NET: DOES IT HAVE HOLES THAT ARE EQUAL TO OR LARGER THAN THE TIP OF YOUR THUMB?
NO 2
128A. OBSERVE OR ASK THE SHAPE OF THE MOSQUITO NET.
RECTANGLE 2
128B. How many times did you wash this mosquito net since you have it?
MORE THAN 95 TIMES 95
NOT SURE 98
128C. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 130)
NOT SURE 8 (SKIP TO 130)
129. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.
LINE NO. __
LINE NO. __
LINE NO. __
LINE NO. __
130. GO BACK TO 123 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
131. When you usually wash your net(s)?
USUALLY WASH
IN THE MORNING 2
IN THE AFTERNOON 3
IN THE EVENING 4
132. Why do you wash your net(s)?
BECAUSE THE NET SMELLS BAD 2
OTHER REASON 6 (SPECIFY) __
133. Which color of the net do you prefer?
BLUE 2
PINK 3
GREEN 4
OTHER 6 (SPECIFY) __