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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)

IDENTIFICATION

NOM DE LA PREFECTURE
NOM DE LA LOCALITE
NAME OF THE HEAD OF THE HOUSEHOLD
CLUSTER NUMBER
NUMERO DE LA STRUCTURE
HOUSEHOLD NUMBER

INTERVIEWER VISITS

VISITS 1,2,3

DATE ____________
INTERVIEWER'S NAME ________
RESULT

COMPLETED 1
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

COMPLETED 1
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

DATE __________
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:

FRENCH 01
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?

YES 1
NO 2

HEAD OF TEAM

NAME _________________
NUMBER ________________

INTRODUCTION AND CONSENT

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 AGREES TO BE INTERVIEWED 1
RESPONDENT DOES NOT AGREE TO BE INTERVIEWED 2 (END)

100. RECORD THE TIME.

HOUR ____________
MINUTE ___________

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 5-9 FOR EACH PERSON.

2A. Are there any other persons such as small children or infants that we have not listed?

YES (ADD TO TABLE)
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?

YES (ADD TO TABLE)
NO

2C. Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not bbeen listed?

YES (ADD TO TABLE)
NO

3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?

HEAD 01
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?

YES 1
NO 2

RESIDENCE

05. Does (NAME) usually live here?

YES 1
NO 2

06. Did (NAME) stay here last night?

YES 1
NO 2

07. AGE: How old is (NAME)?
IF 95 OR MORE, RECORD 95.

IN YEARS _____________

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'.

DAY ______________
MONTH _____________
YEAR ______________

7B. IF 15 YEARS OR OLDER: MARITAL STATUS

What is (NAME)'s current marital status?

MARRIED OR LIVING TOGETHER 1
DIVORCED/SEPARATED 2
WIDOWED 3
NEVER MARRIED AND NEVER LIVED TOGETHER 4

ELIGIBILITY

8. CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49

9. CIRCLE LINE NUMBER OF ALL CHILDREN AGE 0-5

HOUSEHOLD CHARACTERISTICS

101. What is the main source of drinking water for members of your household?

PIPED WATER
PIPED INTO DWELLING 11 (SKIP TO 105)
PIPED INTO YARD/PLOT 12 (SKIP TO 105)
PIPED FROM NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/STANDPIPE 14 (SKIP TO 103)
TUBE WELL OR BOREHOLD 21 (SKIP TO 103)
DUG WELL
PROTECTED WELL 31 (SKIP TO 103)
UNPROTECTED WALL 32 (SKIP TO 103)
WATER FROM SPRING
PROTECTED SPRING 41 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
RAINWATER 51 (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
BOTTLED WATER 91
SACHET WATER 92
OTHER ________________(SPECIFY) 96 (SKIP TO 103)

102. What is the main source of water used for cooking or handwashing?

PIPED WATER
PIPED INTO DWELLING 11 (SKIP TO 106)
PIPED INTO YARD/PLOT 12 (SKIP TO 106)
PIPED FROM NEIGHBOR 13 (SKIP TO 106)
PUBLIC TAP/STANDPIPE 14
TUBE WELL OR BOREHOLD 21
DUG WELL
PROTECTED WELL 31
UNPROTECTED WALL 32
WATER FROM SPRING
PROTECTED SPRING 41
UNPROTECTED SPRING 42
RAINWATER 51
TANKER TRUCK 61
CART WITH SMALL TANK/CANISTER OR INNER TUBE/BARREL 71
SURFACE WATER (RIVER/DAM/LAKE/POND/STREAM/CANAL/IRRIGATION CHANNEL) 81
OTHER ________________(SPECIFY) 96

103. Where is the water source located?

IN OWN DWELLING 1 (SKIP TO 105)
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?

MINUTES ___________
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 OR POUR FLUSH TOILET
FLUSH TO PIPED SEWER SYSTEM 11
FLUSH TO SEPTIC TANK 12
FLUSH TO PIT LATRINE 13
FLUSH TO SOMEWHERE ELSE 14
FLUSH, DON'T KNOW WHERE 15
PIT LATRINE
VENTILATED IMPROVED PIT LATRINE 21
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 (SKIP TO 108)
OTHER ______________(SPECIFY) 96

106. Do you share this toilet facility with other households?

YES 1
NO 2 (SKIP TO 108)

107. Including your own household, how many households use this toilet facility?

NUMBER OF HOUSEHOLDS IF LESS THAN 10 _______
10 OR MORE HOUSEHOLDS 95
DON'T KNOW 98

108. What type of fuel does your household mainly use for cooking?

ELECTRICITY 01
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
NO FOOD COOKED IN HOUSEHOLD 95
OTHER _________________(SPECIFY) 96

109. How many rooms in this household are used for sleeping?

ROOMS ____________

109A. In this household, how many beds are available for sleeping?

NUMBER ____________

110. Does this household own any livestock, herds, other farm animals, or poultry?

YES 1
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'.

a. MILK COWS OR BULLS?
___________________
b. OTHER CATTLE?
___________________
c. HOGS?
___________________
d. GOATS?
___________________
e. SHEEP?
___________________
f. CHICKEN?
___________________
g. PINTADES?
___________________
h. DUCKS?
___________________
i. TURKEYS?
___________________

112. Does any member of this household own any agricultural land?

YES 1
NO 2 (SKIP TO 114)

113. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLE 950.

HECTARES ________.___
95 HECTARES OR MORE 950
DO NOT KNOW 998

114. Does your household have?

a. Electricity?
YES 1
NO 2
b. Radio?
YES 1
NO 2
c. Television?
YES 1
NO 2
d. A non-mobile telephone?
YES 1
NO 2
e. A computer?
YES 1
NO 2
f. A refrigerator?
YES 1
NO 2
g. CD/DVD Player/VCR?
YES 1
NO 2
h. An internet connection?
YES 1
NO 2
i. CFI/Parabolic Antenna?
YES 1
NO 2
j. Washer?
YES 1
NO 2
k. Air conditioner?
YES 1
NO 2
l. Stove?
YES 1
NO 2
m. Fan?
YES 1
NO 2

115. Does any member of your household own:

a. A watch?
YES 1
NO 2
b. A cell phone?
YES 1
NO 2
c. A bicycle?
YES 1
NO 2
d. A motorcycle or motor scooter?
YES 1
NO 2
e. A cart pulled by an animal?
YES 1
NO 2
f. A commercial car or truck?
YES 1
NO 2
g. A motor boat?
YES 1
NO 2

116. Does any member of this household have a bank account?

YES 1
NO 2

116A. During the months of June, July, and August 2017, did your household receive mosquito nets during the campaign of 2017?

YES 1 (SKIP TO 116C)
NO 2
DON'T KNOW 8 (SKIP TO 116C)

116B. Why didn't you receive any mosquito nets then?

NETS DID NOT ARRIVE 1
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?

YES 1 (SKIP TO 119)
NO 2
DON'T KNOW 8 (SKIP TO 119)

116D. WHY DIDN"TYOUR HOUSEHOLD RECEIVE A COUPON FOR FREE MOSQUITO NETS?

THERE WERE NO MORE COUPONS 1
ALREADY HAD ENOUGH MOSQUITO NETS 2
OTHER REASON 6
DON"T KNOW 8

119. Does your household have any mosquito nets?

YES 1
NO 2 (SKIP TO 131)

120. How many mosquito nets does your household have?
IF 7 OR MORE NETS, RECORD '7'.

NUMBER OF NETS ____________________________

MOSQUITO NETS

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).

OBSERVED 1
NOT OBSERVED 2

122. How many months ago did your household get the mosquito net?
IF LESS THAN ONE MONTH AGE, RECORD '00'.

MONTHS AGO _______________
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.

LONG-LASTING INSECTICIDE-TREATED NET (LLIN)
PERMANET 11
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

126. QUESTION?

YES, MASS DISTRIBUTION CAMPAIGN 1 (SKIP TO 128)
YES, ANC 2 (SKIP TO 128)
YES, VACCINATION VISIT 3 (SKIP TO 128)
NO 4

127. Where did you get the net?

GOVERNMENT HEALTH FACILITY 01
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?

YES 1
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.

NAME __________
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

NATURAL MATERIAL

EARTH 11
DUNE 12

RUDIMENTARY MATERIAL

WOOD PLANKS 21
PALM/BAMBOO 22

FINISHED MATERIAL

PARQUET/FINISHED WOOD 31
VINYL/LINOLEUM/ASPHALT 32
TILE 33
CEMENT 34
CARPET 35

OTHER (SPECIFY) _____ 96

132. NOTE THE PRINCIPAL MATERIAL OF THE DWELLING ROOF

NATURAL MATERIAL
NO ROOF 11
THATCH/PALM/LEAVES 12
CLODS OF EARTH 13
RUDIMENTARY MATERIAL
MATS 21
PALMS/BAMBOO 22
WOOD PLANKS 23
CARDBOARD 24
FINISHED MATERIAL
SHEET METAL 31
WOOD 32
ZINC/CEMENT 33
ROOF TILES 34
CEMENT 35
SHINGLES 36
OTHER (SPECIFY) ____

133. NOTE THE PRINCIPAL MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING

NATURAL MATERIAL
NO WALLS 11
DUNG/CANE/PALM 12
EARTH 13
RUDIMENTARY MATERIAL
BAMBOO WITH MUD 21
STONE WITH MUD 22
UNFINISHED ABOBE 23
PLYWOOD 24
CARDBOARD 25
UNFINISHED WOOD 26
FINISHED MATERIAL
CEMENT 31
STONE WITH CEMENT/CEMENT 32
BRICKS 33
CEMENT BLOCKS 34
FINISHED ADOBE 35
WOOD PLANKS/SHINGLES 36
OTHER (SPECIFY) _____ 96

134. RECORD THE TIME

HOUR _______
MINUTES ________

INTERVIEWER'S OBSERVATIONS

COMMENTS ON THE INTERVIEW__

COMMENTS ON INDIVIDUAL QUESTIONS____

OTHER COMMENTS___