RWANDA DEMOGRAPHIC AND HEALTH SURVEY
HOUSEHOLD QUESTIONNAIRE
NATIONAL INSTITUTE OF STATISTICS OF RWANDA
PROVINCE __
DISTRICT __
SECTOR __
NAME OF HOUSEHOLD HEAD __
CLUSTER NUMBER __
STRUCTURE NUMBER __
HOUSEHOLD NUMBER __
HOUSEHOLD SELECTED FOR MAN'S SURVEY AND RDHS BIOMAKER? (1 = YES, 2 = NO) __
HOUSEHOLD SELECTED FOR WOMEN'S DV? (1 = YES, 2 = NO) __
HOUSEHOLD SELECTED FOR MEN'S DV? (1 = YES, 2 = NO) __
HOUSEHOLD SELECTED FOR MICRONUTRIENT BIOMAKER (1 = YES, 2 = NO) __
FIRST VISIT:
DATE __
INTERVIEWER'S NAME __
RESULT* __
NEXT VISIT:
DATE __
TIME __
SECOND VISIT:
DATE __
INTERVIEWER'S NAME __
RESULT* __
NEXT VISIT:
DATE __
TIME __
THIRD VISIT:
DATE __
INTERVIEWER'S NAME __
RESULT* __
FINAL VISIT:
DAY __
MONTH __
YEAR __
INT. NO. __
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 __
TOTAL ELIGIBLE MEN __
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE __
LANGUAGE OF QUESTIONNAIRE 01
LANGUAGE OF INTERVIEW __
NATIVE LANGUAGE OF RESPONDENT __
TRANSLATOR USED (YES = 1, NO = 2) __
LANGUAGE OF QUESTIONNAIRE ENGLISH
LANGUAGE CODES
KINYARWANDA 02
SUPERVISOR
NAME __
NUMBER __
FIELD EDITOR
NAME __
NUMBER __
OFFICE EDITOR
NUMBER __
KEYED BY
NUMBER __
Hello. My name is ____________________________. I am working with National Institute of Statistics of Rwanda. We are conducting a survey about health and other topics 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 onto 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)
MINUTES __
LINE NO.
1.
USUAL RESIDENTS AND VISITORS
2. Please give me the names of the persons who usually live in your 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 art her 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
RELATIONSHIP TO HEAD OF HOUSEHOLD
3. What is the relationship of (NAME) to the head of the household? SEE CODES BELOW
SPOUSE 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
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
BROTHER/SISTER IN LAW 11
NOT RELATED 12
WAGED DOMESTIC WORKER 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
7. How old is (NAME)? IF 95 OR MORE, RECORD '95'.
MARITAL STATUS
8. What is (NAME)'s current marital status?
LIVING TOGETHER 2
DIVORCED 3
SEPARATED 4
WIDOWED 5
NEVER MARRIED AND NEVER LIVED TOGETHER 6
ELIGIBILITY
9. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
10. IF HOUSEHOLD SELECTED FOR MAN'S SURVEY: CIRCLE LINE NUMBER OF ALL MEN AGE 15-59
11. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
IF AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
12. Is (NAME)'s biological mother alive?
NO 2 (GO TO 14)
DK 8 (GO TO 14)
13. Does (NAME)'s biological mother usually live in this household or was she a guest last night? RECORD MOTHER'S LINE NUMBER. IF NO, RECORD '00'.
NO 2
14. Is (NAME)'s biological natural father alive?
NO 2 (GO TO 16)
DK 8 (GO TO 16)
15. Does (NAME)'s biological father usually live in this household or was he a guest last night? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.
NO 2
IF AGE 3 YEARS OR OLDER
EVER ATTENDED SCHOOL
16. Has (NAME) ever attended school?
NO 2 (GO TO 20 OR 21)
17. What is the highest level of school (NAME) has attended? What is the highest grade (NAME) completed in that level?
GRADE __
SEE CODES BELOW
PRIMARY 2
POST-PRIMARY/VOCATIONAL 3
SECONARY 4
UNIVERSITY 5
DON'T KNOW 8
DON'T KNOW 98
IF AGE 3-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE
18. Did (NAME) attend school at any time during the 2019/2020 school year?
NO 2 (GO TO 20 OR 21)
19. During (this/that) school year, what level and grade (is/was) (NAME) attending? SEE CODES ABOVE
GRADE __
IF AGE 0-4 YEARS
BIRTH REGISTRATION
20. Does (NAME) have a birth certificate from civil authority? IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
INSURANCE
21. Is (NAME) covered by any health insurance?
NO 2 (GO TO 23)
DON'T KNOW 8 (GO TO 23)
22. What is (NAME)'s main type of health insurance?
RAMA/RSSB 2
MMI 3
PRIVATE INSURANCE COMPANY 4
EMPLOYER 5
DON'T KNOW 8
IF AGE 7+ YEARS
23. Does (NAME) currently smoke?
NO 2
DON'T KNOW 8
IF AGE 5 OR OLDER
DISABILITY
26. Does (NAME) wear glasses or contact lenses to help them see?
NO 2 (GO TO 28)
27. Does (NAME) have difficulty seeing even when wearing glasses or contact lenses? Would you say that (NAME) has some difficulty, a lot of difficulty, or cannot see at all?
SOME DIFFICULT 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8
28. Does (NAME) have difficulty seeing? Would you say that (NAME) has some difficulty, a lot of difficulty, or cannot see at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT SEE AT ALL 4
DON'T KNOW 8
29. Does (NAME) wear a hearing aid?
NO 2 (GO TO 31)
30. Does (NAME) have difficulty hearing even when using a hearing aid? Would you say that (NAME) has some difficulty, a lot of difficulty, or cannot hear at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT HEAR AT ALL 4
DON'T KNOW 8
31. Does (NAME) have difficulty hearing? Would you say that (NAME) have some difficulty, a lot of difficulty, or cannot hear at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT HEAR AT ALL 4
DON'T KNOW 8
32. Does (NAME) have difficulty communicating when using his/her usual language? Would you say that (NAME) has some difficulty understanding or being understood, some difficulty, a lot of difficulty, or cannot communicate at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT COMMUNICATE AT ALL 4
DON'T KNOW 8
33. Does (NAME) have difficulty remembering or concentrating? Would you say that (NAME) has some difficulty remembering or concentrating, a lot of difficulty, or cannot remember or concentrate at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT REMEMBER/CONCENTRATE AT ALL 4
DON'T KNOW 8
34. Does (NAME) have difficulty walking or climbing steps? Would you say that (NAME) has walking or climbing steps, a lot of difficulty, or cannot walk or climb steps at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT WALK OR CLIMB AT ALL 4
DON'T KNOW 8
35. Does (NAME) have difficulty washing all over or dressing? Would you say that (NAME) has some difficulty washing all over or dressing, a lot of difficulty, or cannot wash all over or dress at all?
SOME DIFFICULTY 2
A LOT OF DIFFICULTY 3
CANNOT WASH OR DRESS AT ALL 4
DON'T KNOW 8
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (SKIP TO 107)
PIPED TO NEIGHBOR 13 (SKIP TO 107)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
UNPROTECTED WELL 32 (SKIP TO 103)
UNPROTETED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK 71 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91 (SKIP TO 103)
OTHER 96 (SPECIFY) __ (SKIP 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 (SKIP TO 107)
PIPED TO NEIGHBOR 13 (SKIP TO 107)
PUBLIC TAP/STANDPIPE 14
UNPROTECTED WELL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STRAM/CANAL/IRRIGATION CHANNEL) 81
OTHER 96 (SPECIFY) ___
103. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 107)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
104A. What is the distance from your home to that water source?
200M -- 500M 2
MORE THAN 500M 3
DON'T KNOW 8
107. Do you do anything to the water to make it safer to drink?
NO 2 (SKIP TO 109)
DON'T KNOW 8 (SKIP TO 109)
108. What do you usually do to make the water safer to drink? Anything else? RECORD ALL MENTIONED.
ADD 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 X (SPECIFY) __
DON'T KNOW Z
108A. Is the water this household uses for drinking stored?
NO 2 (SKIP TO 109)
DON'T KNOW 8 (SKIP TO 109)
108B. ASK TO SEE THE CONTAINER(S) IN WHICH WATER IS TORED. RECORD OBSERVATION.
POT 2
BOTTLE 3
COOKING POT 4
OTHER 6 (SPECIFY) __
NOT AVAILABLE TO BE OBSERVED 8
108C. How many times per week does your household wash these containers?
7 OR MORE TIMS PER WEEK 7
DON'T KNOW 8
109. What kind 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
NO FACILITY/BUSH/FIELD 61 (SKIP TO 113)
OTHER 96 (SPECIFY) __
110. Do you share this facility with other households?
NO 2 (SKIP 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
112A. CLEANLINESS OF THE TOILET FACILITY. RECORD OBSERVATION
WITH URINE OR EXCRETA B
WITH FLIES C
113. What type of fuel does your household mainly use for cooking?
GAS (LPG/NATURAL GAS) 02
BIOGAS 03
KEROSENE 04
PEAT/LIGNITE 05
CHARCOAL 06
WOOD 07
STRAW/SHRUBS/GRASS 08
AGRICULTURAL CROP 09
ANIMAL DUNG 10
BRIQUETTE 11
SAW DUST 12
NO FOOD COOKED IN HOUSEHOLD 95 (SKIP TO 116)
OTHER 96 (SPECIFY) __
114. Is the cooking usually done in the house, in a separate building, or outdoors?
IN A SEPARATE BUILDING 2 (SKIP TO 116)
OUTDOORS 3 (SKIP TO 116)
OTHER 6 (SPECIFY) __
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 (SKIP TO 119)
118. How many of the following animals does this household own? IF NONE, RECORD '00'. IF 95 OR ORE, RECORD '95'. IF UNKNOWN, RECORD '98'.
a) Milk cows traditional?
b) Milk cows modern?
c) Bulls?
d) Goats?
e) Sheep?
f) Chickens or other poultry?
g) Pigs?
h) Rabbits?
i) Horses, donkeys, or mules?
b) MILK COWS MODERN __
c) BULLS __
d) GOATS __
e) SHEEP __
f) CHICKENS/POULTRY __
g) PIGS __
h) RABBIT __
i) HORSES, DONKEYS, MULES __
119. Does any member of this household own any agricultural land?
NO 2 (SKIP TO 121)
120. 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
121. Does your household have:
a) Electricity?
b) A radio?
c) A television?
d) A non-mobile telephone?
e) A computer?
g) A refrigerator?
h) A bench or at least 3 chairs?
i) A bed?
j) A table?
k) A sofa?
l) A traditional improved stove?
m) A stove?
n) A cupboard?
o) A dining table?
p) Iron machine?
q) A laundry machine?
r) A satellite dish?
a) ELECTRICITY
NO 2
b) RADIO
NO 2
c) TELEVISION
NO 2
d) NON-MOBILE TELEPHONE
NO 2
e) COMPUTER
NO 2
f) REFRIGERATOR
NO 2
g) MATTRESS
NO 2
h) BENCH OR AT LEAST 3 CHAIRS
NO 2
i) BED
NO 2
j) TABLE
NO 2
k) SOFA
NO 2
l) MODERN STOVE
NO 2
m) STOVE
NO 2
n) CUPBOARD
NO 2
o) DINING TABLE
NO 2
p) IRON
NO 2
q) LAUNDRY MACHINE
NO 2
r) SATELITE DISH
NO 2
122. Does any member of this household own:
a) A watch?
b) A mobile phone?
c) A bicycle?
d) A motorcycle or motor scooter?
e) An animal-drawn cart?
f) A car or truck?
g) A boat with a motor?
h) A boat without a motor?
i) A camera?
a) WATCH
NO 2
b) MOBILE PHONE
NO 2
c) BICYCLE
NO 2
d) MOTORCYLE/SCOOTER
NO 2
e) ANIMAL-DRAWN CART
NO 2
f) CAR/TRUCK
NO 2
g) BOAT WITH MOTOR
NO 2
h) BOAT WITHOUT MOTOR
NO 2
i) CAMERA
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
ALL 'YES' (SKIP TO 127)
12B. Does your household plan to obtain health insurance for members that are currently not covered?
NO 2
127. Does your household have any mosquito nets?
NO 2 (SKIP TO 139)
128. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
129. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
130. How many months ago did your household get the mosquito net? IF LESS THAN ONE MONTH AGO, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
131. OBSERVE OR ASK BRAND/TYPE OF MOSQUITO NET. IF BRAND IF UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
ROYAL SENTRY 11
DAWAPLUS 2.0 12
INTERCEPTOR G2 13
YAHE 14
PERMANET 3.0 15
MIRANET 16
OTHER/DON'T KNOW BRAND 17
OTHER TYPE 96
DON'T KNOW TYPE 98
134. Did you get the net through a HH Mosquito net mass distribution campaign, during an antenatal care visit, or during an immunization visit?
YES, ANC 2 (SKIP TO 136)
YES, IMMUNIZATION VISIT 3 (SKIP TO 136)
NO 4
135. Where did you get the net?
DISTRICT PHARMACY 02
PRIVATE PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
OTHER 96
DON'T KNOW 98
135A. OBSERVE CONDITION OF MOSQUITO NET: DOES IT HAVE HOLES THAT ARE EQUAL TO OR LARGER THAN THE TIP OF YOUR THUMB?
NO 2
NOT OBSERVED 8
135B. OBSERVE OR ASK THE SHAPE OF THE MOSQUITO NET.
RECTANGLE 2
NOT OBSERVED 8
136. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 137A)
NOT SURE 8 (SKIP TO 137A)
137. Who slept under this mosquito net last night? RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE
LINE NO. __
(SKIP TO 138)
137A. Why did no one sleep under this mosquito net?
DIFFICULT TO HANG 2
NO SLEEPING BED 3
DON'T LIKE IT 4
ABSENT LAST NIGHT 5
OTHER 6 (SPECIFY) __
DON'T KNOW 8
138. 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?
OBSERVED, MOBILE 2
NOT OBSERVED, NOT IN DWELLING/YARD/PLOT 3 (SKIP TO 142)
NOT OBSERVED, NO PERMISSION TO SEE 4 (SKIP TO 142)
NOT OBSERVED, OTHER REASON 5 (SKIP TO 142)
140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.
WATER IS NOT AVAILABLE 3
141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.
ASH, MUD, SAND B
NONE Y
142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.
DUNG 12
BRICKS WITHOUT CEMENT 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES/COASTAL BRICK 33
CEMENT 34
CARPET 35
143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELING. RECORD OBSERVATION.
THATCH/PALM LEAF 12
CALAMINE/CEMENT FIBER 32
CERAMIC TILES 33
CEMENT/CONCRETE 34
INDUSTRIAL TILES 35
OTHER 96 (SPECIFY) __
144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSREVATION.
STONE WITH MUD 22
UNCOVERED ADOBE 23
REUSED WOOD 24
PLASTIC SHEETING 25
STONE WITH LIME/CEMENT 32
OVEN FIRED BRICKS 33
OVEN FIRED BRICKS WITH CEMENT 34
CEMENT BLOCK 35
COVERED ADOBE WITH CEMENT 36
WOOD PLANKS/SHINGLES 37
144A. CHECK COVER PAGE: HOUSEEHOLD SELECTED FOR MICRONUTRIENT BIOMAKER.
NO 2 (SKIP TO 146)
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?
COLLECT SALT AND PLACE IN INDICATED CONTAINER
PUT THE 2ND BAR CODE LABEL ON SALT CONTAINEE, AND THE 3RD ON THE TRANSMITTAL FORM.
PUT THE 1ST BAR CODE LABEL HERE.
REFUSED 99995 (SKIP TO 146)
OTHER 99996 (SPECIFY REASON) __ (SKIP TO 146)
LARGE CRYSTAL SALT 2
OTHER 6
MINUTES __
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW: __
COMMENTS ON SPECIFIC QUESTIONS: __
ANY OTHER COMMENTS: __
SUPERVISOR'S OBSERVATIONS
EDITOR'S OBSERVATIONS