Sierra Leone
Statistics Sierra Leone
IDENTIFICATION
LOCALITY NAME ___
LOCAL COUNCIL___
NAME OF HOSUEHOLD HEAD___
PROVINCE NAME AND CODE___
DISTRICT CODE___
CHIEFDOM CODE___
SECTION CODE___
CLUSTER NUMBER___
ENUMERATION AREA CODE___
RURAL/URBAN
URBAN 2
HOUSEHOLD NUMBER___
HOUSEHOLD SELECTED FOR MAN'S SURVRY?
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) ___
NEXT VISIT
DATE___
TIME___
FINAL VISIT
DAY___
MONTH___
YEAR___
INT. NO___
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) ___
TOTAL NUMBER OF VISITS___
TOTAL ELIGIBLE WOMEN___
TOTAL ELIGIBLE MEN___
LINE NUMBER OF RESPONDENT___
TOTAL ELIGIBLE GIRLS___
LANGUAGE OF QUESTIONNAIRE: 01
LANGUAGE OF INTERVIEW___
02 CREOLE
03 TEMNE
04 LANGUAGE 4
05 LANGUAGE 5
06 LANGUAGE 6
FIELD EDITOR
NAME___
NUMBER___
OFFICE EDITOR
NUMBER___
KEYED BY
NUMBER___
"Hello. My name is _______________________________________. I am working with Statistics Sierra Leone. We are conducting a survey about health and other topics all over Sierra Leone. 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)
MINUTES___
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 AS 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 head of household?
WIDE 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
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON'T KNOW 12
4. SEX: Is (NAME) male or female?
FEMALE 2
5. Does (NAME) usually live here?
NO 2
6. Did (NAME) stay here last night?
NO 2
7. AGE: How old is (NAME)?
IF 95 OR MORE YEARS, RECORD '95'
8. MARITAL STATUS: What is (NAME)'s Current Marital Status?
DIVORCED/SEPARTED 2
WIDOWED 3
NEVER-MARRIED AND NEVER LIVED TOGETHER 4
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 WOMEN AGE 0-5
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS
12. Is (NAME)'s natural mother alive?
NO 2
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
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'
EVER ATTENDED SCHOOL
16. Has (NAME) ever attended school?
NO 2
17. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
LEVEL___
1 PRIMARY
2 JSS (MIDDLE SCHOOL)
3 SSS (HIGH SCHOOL)
4 VOCATIONAL/TECH/NURSING/TEACHER
5 HIGHER
8 DON'T KNOW
*FOR 'HIGHER' TOTAL THE NUMBER OF YEARS THE POST-SECONDARY LEVEL
GRADE___
1-6
1-3
1-3
1-3
1-7
98 DON'T KNOW
CURRENT/RECENT SCHOOL ATTENDANCE
18. Did (NAME) attend school at any time during 2018-2019 school year?
NO 2
19. During this school year what level and grade was (NAME) attending?
LEVEL___
1 PRIMARY
2 JSS (MIDDLE SCHOOL)
3 SSS (HIGH SCHOOL)
4 VOCATIONAL/TECH/NURSING/TEACHER
5 HIGHER
8 DON'T KNOW
GRADE___
1-3
1-3
1-3
1-7
98 DON'T KNOW
BIRTH REGISTRATION
20. Does (NAME) have a birth certificate?
IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?
REGISTERED 2
NEITHER 3
DON'T KNOW 8
101. What is the main source of drinking water for members of your household?
PIPED TO YARD/PLOT 12 (GO TO 106)
PUBLIC TAP/STANDPIPE 13 (GO TO 106)
PIPED TO NEIGHBOR 14 (GO TO 103)
TUBE WELL OR BOREHOLE 21(GO TO 103)
DUG WELL
UNPROTECTED WATER 32 (GO TO 103)
WATER FROM SPRING
UNPROTECTED SPRING 42 (GO TO 103)
RAINWATER 51 (GO TO 103)
TANKER TRUCK 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/ SACHET 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)
PUBLIC TAP/STANDPIPE 13 (GO TO 106)
PIPED TO NEIGHBOR 14
TUBE WELL OR BOREHOLE 21
DUG WELL
UNPROTECTED WATER 32
WATER FROM SPRING
UNPROTECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
BOTTLED WATER/ SACHET WATER 91
OTHER (SPECIFY)___ 96
103. Where is that water source located?
IN ON YARD 2 (GO TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105. CHECK 101 AND 102: CODE'14 OR '21'
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
DON'T KNOW 8
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 kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE ASK PERMISSION TO OBSERVE THE FACULTY.
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
PIT LATRINE WITH SLAB 22
PIT LATRINE WITHOUT SLAB/OPEN PIT 23
COMPOSTING TOILET 31
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
KEROSEN 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUB/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95 (GO TO 116)
OTHER (SPECIFY) ___ 96
114. Is the cooking 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'.
a) Milk cows or bulls?
b) Other cattle?
c) Horses, donkeys or mules?
d) Goats?
e) Sheep?
f) Chicken or other poultry?
119. does any members of this household own any agricultural land?
NO 2
120. Does 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 this household have:
a) Electricity?
NO 2
b) A Radio?
NO 2
c) A Television?
NO 2
d) A Non-mobile telephone?
NO 2
e) A Computer?
NO 2
f) A Refrigerator?
NO 2
122. Does any member of the household own:
a) A watch?
NO 2
b) A mobile phone?
NO 2
c) A bicycle?
NO 2
d) A motorcycle or motor scooter?
NO 2
e) An animal-drawn cart wheelbarrow?
NO 2
f) A car or truck?
NO 2
g) A boat with a motor?
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
127. Does your household have any mosquito nets?
NO 2 (GO 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 IS UNKNOWN AND YOU CANNOT OBSERVE THE NET, SHOW PICTURES OF TYPICAL NET TYPES/BRANDS TO RESPONDENT.
BRAND B 12
OTHER/DON'T KNOW BRAND 16
DON'T KNOW TYPE 98
134. Did you get the net through a [LOCAL NAME OF MASS DISTRIBUTION CAMPAIGN], during an antenatal care visit, or during an immunization visit?
YES, ANTENATAL CARE 2 (GO TO 136)
YES, IMMUNIZATION VISIT 3 (GO TO 136)
NO 4 (GO TO 136)
135. Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
CHW 05
RELIGIOUS INSTITUTION 06
SCHOOL 07
OTHER 96
DON'T KNOW 98
136. Did anyone sleep under this mosquito net last night?
NO 2 (GO TO 138)
NOT SURE (GO TO 138)
137. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE
LINE NO___
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/YEARD/PLOT 3
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 Y
142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING.
RECORD OBSERVATION.
DUNG 12
RUDIMENTARY FLOOR
PALM/BAMBOO 22
FINISHED FLOOR
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
OTHER (SPECIFY) ________ 96
143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/PALM LEAVES 12
SOD 13
RUDIMENTARY ROOFING
PALM/BAMBOO 22
WOOD PLANK 23
CARDBOARD 24
FINISHED ROOFING
WOOD 32
CALAMINE/SEMENT FIBER 33
CERAMIC TILES 34
CEMENT 35
ROOFING SHINGLES 36
OTHER (SPECIFY)____ 96
144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
CANE/PALM.TRUNKS 12
DIRT 13
RUDIMENTARY WALLS
STONE WITH MUD 22
UNCOVERED ADOBE 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
TARPAULIN 27
FINISHED WALLS
STONE WITH LIME/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
COVERED ADOBE 35
WOOD PLANKS/SHINGLES 36
TILES 37
OTHER (SPECIFY) ___ 96
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?
TEST SALT FOR IODINE.
NO IODINE 2
NO SALT IN HOUSEHOLD 3
SALT NOT TESTED (SPECIFY REASON) _____ 6
MINUTE_____
INTERVIEWERS OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW_______
COMMENTS ON SPECIFIC QUESTIONS______
ANY OTHER COMMENTS______
SUPERVISORS OBSERVATIONS______
EDITORS OBSERVATION______