MALARIA INDICATORS SURVEY
EIP - TOGO 2017
HOUSEHOLD QUESTIONNAIRE
MINISTRY OF HEALTH AND SOCIAL PROTECTION
INSTITUT NATIONAL DE LA STATISTIQUE ET DES ÉTUDES ÉCONOMIQUES ET DÉMOGRAPHIQUES (INSEED)
NOM DE LA PREFECTURE
NOM DE LA LOCALITE
NAME OF THE HEAD OF THE HOUSEHOLD
CLUSTER NUMBER
NUMERO DE LA STRUCTURE
HOUSEHOLD NUMBER
VISITS 1,2,3
DATE ____________
INTERVIEWER'S NAME ________
RESULT
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 (SPECIFY) 9
FINAL VISIT
DAY ______________
MONTH ____________
YEAR 2017
INTERVIEWER NUMBER _________
RESULT
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 (SPECIFY) 9
NEXT VISIT
TIME __________
TOTAL NUMBER OF VISITS ________________
TOTAL PERSONS IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE
LANGUAGE OF QUESTIONNAIRE: FRENCH 01
LANGUAGE OF THE INTERVIEW:
EWE/MINA 02
KABYE 03
KOTOKOLI/TEM 04
AKPOSSO/AKEBOU 05
IFE/ANA 06
MOBA-GOURMA 07
TCHOKOSSI 08
BASSAR/KONKOMBA 09
OTHER NATIONAL LANGUAGE ____________(SPECIFY) 96
OTHER FOREIGN LANGUAGE ____________(SPECIFY) 97
TRANSLATOR USED?
NO 2
HEAD OF TEAM
NUMBER ________________
Hello. My name is ______________. PLEASE TRANSLATE THE REST.
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)
MINUTE ___________
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 5-9 FOR EACH PERSON.
2A. Are there any other persons such as small children or infants that we have not listed?
NO
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?
NO
2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not bbeen listed?
NO
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the 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
OTHER RELATIVE 09
ADOPTED/FOSTER/STEPCHILD 10
NOT RELATED 11
DON'T KNOW 98
04. SEX: Does (NAME) usually live here?
NO 2
05. Does (NAME) usually live here?
NO 2
06. Did (NAME) stay here last night?
NO 2
07. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD 95.
7A. IF AGE 0-6 YEARS: DATE OF BIRTH
What day, month, and year was (NAME) born?
IF DON'T KNOW THE DAY, RECORD '98'.
IF DON'T KNOW THE MONTH, RECORD '98'.
IF DON'T KNOW THE YEAR, RECORD '9998'.
MONTH _____________
YEAR ______________
7B. IF 15 YEARS OR OLDER: MARITAL STATUS
What is (NAME)'s current marital status?
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED AND NEVER LIVED TOGETHER 4
8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5
101. What is the main source of drinking water for members of your household?
PIPED INTO YARD/PLOT 12 (SKIP TO 105)
PIPED FROM NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
UNPROTECTED WALL 32 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
CART WITH SMALL TANK/CANISTER OR INNER TUBE/BARREL 71 (SKIP TO 103)
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
SACHET WATER 92
102. What is the main source of water used for cooking or handwashing?
PIPED INTO YARD/PLOT 12 (SKIP TO 106)
PIPED FROM NEIGHBOR 13 (SKIP TO 106)
PUBLIC TAP/STANDPIPE 14
UNPROTECTED WALL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK/CANISTER OR INNER TUBE/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
103. Where is the water source located?
IN OWN YARD/PLOT 2 (SKIP TO 105)
ELSEWHERE 3
104. How long does it take you to go there, get water, and come back?
DON'T KNOW 998
105. 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
BUCKET TOILET 41
HANGING TOILET/HANGING LATRINE 51
NO FACILITY/BUSH/FIELD 61 (SKIP TO 108)
106. Do you share this toilet facility with other households?
NO 2 (SKIP TO 108)
107. Including your own household, how many households use this toilet facility?
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98
108. What type of fuel does your household mainly use for cooking?
LPG 02
NATURAL GAS/BUTANE GAS 03
BIOGAS 04
KAROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROPS 10
ANIMAL DUNG 11
SAWDUST 12
OTHER _________________(SPECIFY) 96
109. How many rooms in this household are used for sleeping?
109A. In this household, how many beds are available for sleeping?
110. Does this household own any livestock, herds, other farm animals, or poultry?
NO 2 (SKIP TO 112)
111. How many of the following animals does this household own?
IF NONE, ENTER '00'.
IF 95 OR MOREE, ENTER '95'.
IF UNKNOWN, ENTER '98'.
112. Does any member of this household own any agricultural land?
NO 2 (SKIP TO 114)
113. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950.
95 HECTARES OR MORE 950
DO NOT KNOW 998
114. Does your household have?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
115. Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
116. Does any member of this household have a bank account?
NO 2
116A. During the months of June, July, and August 2017, did your household receive mosquito nets during the campaign of 2017?
NO 2
DON'T KNOW 8 (SKIP TO 116C)
116B. Why didn't you receive any mosquito nets then?
NO ONE AT HOME 2
WE REFUSED THEM 3
ARRIVED AFTER THE CAMPAIGN 4
REFUSED BY OFFICIALS 5
OTHER REASON 6
DON'T KNOW 8
116C. AFTER JUNE 2017, DID YOUR HOUSEHOLD RECEIVE A COUPON TO RECCEIVE A FREE MOSQUITO NET AFTER THE CAMPAIGN OF 2017?
NO 2
DON'T KNOW 8 (SKIP TO 119)
116D. WHY DIDN"TYOUR HOUSEHOLD RECEIVE A COUPON FOR FREE MOSQUITO NETS?
ALREADY HAD ENOUGH MOSQUITO NETS 2
OTHER REASON 6
DON"T KNOW 8
119. Does your household have any mosquito nets?
NO 2 (SKIP TO 131)
120. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.
Net 1, Net 2, Net 3
121. ASK THE RESPONDENT TO SHOW YOU THE NETS IN THE HOUSEHOLD.
IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
122. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGE, RECORD '00'.
MORE THAN 36 MONTHS AGO 95
NOT SURE 98
123. 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.
OLYSET 12
DURANET 13
BEST NET/NET PROTECT 14
ICON LIFE 15
INTERCEPTOR 16
YORKOOR 17
OTHER/DON'T KNOW BRAND 20
OTHER TYPE 96
DON'T KNOW 98
YES, ANC 2 (SKIP TO 128)
YES, VACCINATION VISIT 3 (SKIP TO 128)
NO 4
127. Where did you get the net?
PRIVATE HEALTH FACILITY 02
PHARMACY 03
SHOP/MARKET 04
COMMUNITY FIELD AGENT 05
RELIGIOUS INSTITUTION 06
SCHOOL 07
OTHER 96
DON'T KNOW 98
128. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 130)
DON'T KNOW (SKIP TO 130)
129. Who slept under the mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NUMBER _____________
130. GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
OTHER CHARACTERISTICS OF THE DWELLING
131. NOTE THE PRINCIPAL MATERIAL OF THE DWELLING FLOOR
EARTH 11
DUNE 12
WOOD PLANKS 21
PALM/BAMBOO 22
PARQUET/FINISHED WOOD 31
VINYL/LINOLEUM/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35
132. NOTE THE PRINCIPAL MATERIAL OF THE DWELLING ROOF
THATCH/PALM/LEAVES 12
CLODS OF EARTH 13
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
WOOD 32
ZINC/CEMENT 33
ROOF TILES 34
CEMENT 35
SHINGLES 36
133. NOTE THE PRINCIPAL MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING
DUNG/CANE/PALM 12
EARTH 13
STONE WITH MUD 22
UNFINISHED ABOBE 23
PLYWOOD 24
CARDBOARD 25
UNFINISHED WOOD 26
STONE WITH CEMENT/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
FINISHED ADOBE 35
WOOD PLANKS/SHINGLES 36
MINUTES ________
COMMENTS ON THE INTERVIEW__
COMMENTS ON INDIVIDUAL QUESTIONS____
OTHER COMMENTS___