August 2015

UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS

QST. No. ______

IDENTIFICATION

REGION _____

DISTRICT _____

WARD _____

LARGE CITY, MUNICIPALITY, SMALL TOWN, COUNTRISIDE (1)

NAME OF HOUSEHOLD HEAD _____

HOUSEHOLD NUMBER _____

HOUSEHOLD SELECTED FOR MAN'S SURVEY, SALT AND URINE TESTING?

(1) CITY: DSM, TANGA, MWANZA. MUNICIPALITY= DODOMA, KILIMANJARO, MOROGORO, PWANI, LINDI, MTWARA, SONGEA, IRINGA, SINGIDA, TABORA, RUKWA, SHINYANGA, KAGERA, MARA, MJIONI MAGHARIBI, WETE, CHAKE CHAKE, MKOANI. SMALL TOWN: ALL OTHER CITIES. RURAL: ALL OTHER AREAS.

INTERVIEWER VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)

*RESULT CODES

NEXT VISIT

FINAL VISIT

TOTAL NUMBER OF VISITS _____

TOTAL PERSONS IN HOUSEHOLD _____
TOTAL ELIGIBLE WOMEN _____
TOTAL ELIGIBLE MEN _____
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE _____

LANGUAGE OF QUESTIONNAIRE: ENGLISH 01
LANGUAGE OF INTERVIEW: _______

TRANSLATOR USED

SUPERVISOR

FIELD EDITOR

OFFICE EDITOR

KEYED BY

INTRODUCTION AND CONSENT

Hello. My name is ____________________. I am working with the National Bureau of Statistics (NBS). We are conducting a survey about health and other topics all over the United Republic of Tanzania. 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 20 to 25 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 how 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 ______

100. RECORD THE TIME.

HOUSEHOLD SCHEDULE

1. LINE NO.

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 COLUMN 5-25 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?

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?

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

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

4. SEX: Is (NAME) male or female?

5. RESIDENCE: Does (NAME) usually live here?

6. RESIDENCE: Did (NAME) stay here last night?

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

8. IF AGE 15 OR OLDER -- MARITAL STATUS
What is (NAME)'s current marital status?

ELIGIBILITY: CHECK COLUMN 4 AND 7

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 15-49

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

CHECK COLUMN 7, IF AGE 0-17 YEARS
SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS

12. Is (NAME)'s natural mother alive?

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?

15. Does (NAME)'s natural father usually live in this household or was he a guest last night? IF YES: What was his name? RECORD FATHER'S LINE NUMBER. IF NO, RECORD '00'.

CHECK COLUMN 7, IF AGE 0-4 YEARS
BIRTH REGISTRATION

16. Does (NAME) have a birth certificate? IF NO, PROBE: Has (NAME)'s birth ever been registered with the civil authority?

CHECK COLUMN 7, IF AGE 5 YEARS OR OLDER
EVER ATTENDED SCHOOL

17. Has (NAME) ever attended school?

18. What is the highest level of school (NAME) has attended?
What is the highest grade (NAME) completed at that level?
SEE CODES BELOW.

CHECK COLUMN 7, IF AGE 5-24 YEARS
CURRENT/RECENT SCHOOL ATTENDANCE

19. Did (NAME) attend school at any time during the 2015 school year?

20. During [this/that] school year, what level and grade [is/was] (NAME) attending?
SEE CODES BELOW

HEALTH INSURANCE

20A. Is (NAME) covered by any health insurance?

20B. What is (NAME)'s main type of health insurance?
SEE CODES BELOW.

INPATIENT

21. In the last six months, was (NAME) admitted overnight to stay at a health facility?

22. CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR INPATIENT MODULE. CHECK COLUMN 21: CODE '1' 'YES' CIRCLED.

OUTPATIENT

23. In the last four weeks, did (NAME) receive care from a health provider, a pharmacy, or a traditional healer without staying overnight?

24. The last time (NAME) received care, was any money paid?

25. CIRCLE LINE NUMBER OF HOUSEHOLD MEMBER ELIGIBLE FOR OUTPATIENT MODULE. CHECK COLUMN 24: CODE '1' 'YES' CIRCLED.

HOUSEHOLD CHARACTERISTICS

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

101A. Which agency is providing water at your main source?

102. What is the main source of water used by your household for other purposes such as cooking and handwashing?

103. Where is that water source located?

104. How long does it take to go there, get water, and come back?

104A.Who usually goes to the source to collect water for your household? PROBE: Is this person under age 15? What sex?

105. CHECK 101 AND 102: CODE '14' OR '21' CIRCLED?

106. In the past two weeks, was the water from this source not available for at least one full day?

107. Do you do anything to the water to make it safer to drink?

108. What do you usually do to make the water safer to drink? Anything else?
RECORD ALL MENTIONED.

109. What kind of toilet facility do members of your household usually use?
IF NOT POSSIBLE TO DETERMINE, ASK PERMISSION TO OBSERVE THE FACILITY.

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

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

112. Where is this toilet facility located?

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

114. Is the cooking usually done in the house, in a separate building, or outdoors?

115. Do you have a separate room which is used as a kitchen?

115A. What is the main source of energy for lighting in the household?

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

116A. How many sleeping spaces such as mats, rugs, mattresses or beds are used in this household?

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

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) Chickens or other poultry?

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

120. How many hectares of agricultural land do members of this household own?
IF 95 OR MORE, CIRCLED '950'.

121. Does your household have:

a) Electricity that is connected?
b) A radio in working condition?
c) A television in working condition?
d) A non-mobile telephone in working condition?
e) A computer in working conditions?
f) A refrigerator in working condition?
g) A battery or Generator for power?
h) An iron (charcoal or electricity)?

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?

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

123A. How far is it to the nearest market place?
IF LESS THAN ONE KM, ENTER 00. IF MORE THAN 95 KM, ENTER 95.

124. How often does anyone smoke inside your house? Would you say daily, weekly, monthly, less often than once a month, or never?

124A. Now I would like to ask you about the food your household eats. How many meals does your household usually have per day?

124B. In the past week, on how many days did the household eat meat or fish?

124C. How often in the last years did you have problems in satisfying the food needs of the household?

124D. In the past four weeks, was there ever no food to eat of any kind in your household because of lack of resources to get food? Would you say it never happened? Rarely happened? Happened sometimes or often?

124E. In the past four weeks, did you or any household member go to sleep at night hungry because there was not enough food? Would you say it never happened? Rarely happened? Happened sometimes or often?

124F. In the past four weeks, did you or any household member go a whole day and night without eating anything because there was not enough food? Would you say it never happened? Rarely happened? Happened sometimes or often?

124G. How far is it to the nearest health facility?
IF LESS THAN ONE KM, ENTER '00'. IF MORE THAN 95 KM, ENTER '95'.

124H. If you were to go to the nearest health facility, how would usually you go there?

124I. Did your household ever receive any (NAME OF ASSISTANCE) from government or non-government organizations?

124J. What is the name of the organization or program that provided this assistance?

124J1. CHECK 124I, AT LEAST ONE YES CIRCLED?

124K. When was the last time you received an assistance?
IF LESS THAN 2 YEARS, RECORD NUMBER OF MONTH. IF LESS THAN 1 MONTH, RECORD '00'.

125. At any time in the past 12 months, has anyone come into your dwelling to spray the interior walls against mosquitoes?

126. Who sprayed the dwelling?

127. Does your household have any mosquito nets?

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 6 NETS, USE ADDITIONAL

129A. IF NET OBSERVED, RECORD ITS COLOR(S). IF NET NOT OBSERVED, ASK: What color is the net?

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

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.

134. Did you get the net through Government's net distribution campaign to households, during an antenatal care visit, during an immunization visit or through the school net programme (SNP)?

135. Where did you get the net?

136. Did anyone sleep under this mosquito net last night?

137. Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.

GO BACK TO Q129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO Q139.

137A. Why not?
RECORD ALL MENTIONED.

138. GO BACK TO 129 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 139.

139. We would like to learn about the places that households use to wash their hands. Can you show me where members of your household most often was their hands?

140. OBSERVE PRESENCE OF WATER AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.

141. OBSERVE PRESENCE OF SOAP, DETERGENT, OR OTHER CLEANSING AGENT AT THE PLACE FOR HANDWASHING. RECORD OBSERVATION.

142. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.

143. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION.

144. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.

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.

146. CHECK COVER OF HOUSEHOLD QUESTIONNAIRE. IF HOUSEHOLD SELECTED FOR ADDITIONAL SALT TESTING ASK FOR ADDITIONAL FULL TABLESPOON OF SALT. PLACE SALT IN CONTAINER.

INPATIENT HEALTH EXPENDITURES MODULE

201. CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE:

202. CHECK COLUMN 22 IN HOUSEHOLD SCHEDULE: ENTER THE LINE NUMBER AND NAME OF EACH HOUSEHOLD MEMBER WHO WAS AN INPATIENT. THEN ASK: Now I would like to ask some questions about the household members who stayed overnight in a health facility in the last six months. (IF THERE ARE MORE THAN 3 INPATIENTS, USE ADDITIONAL QUESTIONNAIRE).

203. LINE NUMBER FROM COLUMN 22 IN HOUSEHOLD SCHEDULE

204. NAME FROM COLUMN 2 IN HOUSEHOLD SCHEDULE

205. Where did (NAME) most recently stay overnight for health care?

206. What was the main reason for (NAME) to seek care this most recent time?

207. How much money in total did you or any other member of your household spend on the treatment and services (NAME) received during the most recent overnight stay? We want to know about all the costs for the stay including

208. Did (NAME) stay overnight at a health facility another time in the last six months?

209. Where did (NAME) stay the next-to-last time (he/she) stayed overnight for health care?

210. What was the main reason for (NAME) to seek care this next-to-last time?

211. How much money in total did you or any other member of your household spend on the treatment and services (NAME) received during the next-to-last overnight stay? We want to know about all the costs for the stay, including any charges for laboratory

212. Besides the two stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

213. Where did (NAME) stay the second-to-last time (he/she) stayed overnight for health care?

214. What was the main reason for (NAME) to seek care this second-to-last time?

215. How much money did you or any other member of your household spend on the treatment and services (NAME) received during the second-to-last overnight stay? We want to know about all the costs for the stay, including

216. Besides the three stays you have told me about, did (NAME) stay overnight in a health facility another time in the last six months?

217. In total, how many times did (NAME) stay overnight in a health facility in the last six months?

220. GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE INPATIENTS, GO TO 301.

SELECTION FOR OUTPATIENT HEALTH EXPENDITURES MODULE

301. CHECK COLUMN 25:

TABLE FOR SELECTION OF OUTPATIENT WHO PAID FOR CARE THE LAST TIME SOUGHT CARE IN THE LAST FOUR WEEKS

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE OUTPATIENTS (COLUMN 25) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE PERSON SELECTED FOR THE OUTPATIENT QUESTIONS FROM THE LIST OF ELIGIBLE OUTPATIENTS IN COLUMN 25 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED OUTPATIENT IN Q302.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 25 SHOWS THAT THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE OUTPATIENTS IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND OUTPATIENT WHO IS ELIGIBLE FOR THE OUTPATIENT QUESTIONS (LINE NUMBER '04' IN THIS EXAMPLE). WRITE THE NAME AND LINE NUMBER OF THE

*(see pdf for table)*

302.

303. Now I would like to ask some questions about health care that (NAME IN 302) received in the last four weeks, without having to stay overnight. Where did (NAME) get care most recently without staying overnight?

304. How much money in total did you or any other member of your household spend on treatment and services (NAME) received from (NAME OF PROVIDER IN 303)? Please include the consulting fee and any expenses for other items including drugs and tests.

305. What was the main reason for (NAME) to seek care this most recent time?

306. Did (NAME) get care another time in the last four weeks from a health provider, a pharmacy, or a traditional healer without staying overnight?

307. How many other times did (NAME) get care in the last four weeks?

308. How many times was money spent?

311. Sometimes people buy vitamins, medicines, and herbal remedies without consulting with a health provider, pharmacy, or traditional healer. They may also buy other health-related items such as Band-Aids/plasters, thermometers, or other medical devices, and so on without a consultation. In the last four weeks, how much money was spent on these types of health-related items for members of your household?

312A. CHECK COLUMN 9:

LOOK AT THE LAST DIGIT OF THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER ON THE COVER PAGE. THIS IS THE ROW NUMBER YOU SHOULD GO TO. CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN (COLUMN 9) IN THE HOUSEHOLD SCHEDULE. THIS IS THE COLUMN NUMBER YOU SHOULD GO TO. FOLLOW THE SELECTED ROW AND COLUMN TO THE CELL WHERE THEY MEET AND CIRCLE THE NUMBER IN THE CELL. THIS IS THE NUMBER OF THE WOMAN SELECTED FOR THE DOMESTIC VIOLENCE QUESTIONS FROM THE LIST OF ELIGIBLE WOMEN IN COLUMN 9 OF THE HOUSEHOLD SCHEDULE. WRITE THE NAME AND LINE NUMBER OF THE SELECTED WOMAN IN THE SPACE BELOW THE TABLE.
EXAMPLE: THE HOUSEHOLD QUESTIONNAIRE SERIAL NUMBER IS '716' AND THE HOUSEHOLD SCHEDULE COLUMN 9 SHOWS THAT THERE ARE THREE ELIGIBLE WOMEN AGE 15-49 IN THE HOUSEHOLD (LINE NUMBERS 02, 04, AND 05). SINCE THE LAST DIGIT OF THE HOUSEHOLD SERIAL NUMBER IS '6' GO TO ROW '6' AND SINCE THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'. FOLLOW THE ROW AND COLUMN AND FIND THE NUMBER IN THE CELL WHERE THEY MEET ('2') AND CIRCLE THE NUMBER. NOW GO TO THE HOUSEHOLD SCHEDULE AND FIND THE SECOND WOMAN WHO IS ELIGIBLE FOR THE WOMAN'S INTERVIEW (LINE NUMBER '04' IN THIS EXAMPLE). WRITE HER NAME AND LINE NUMBER IN THE
*(see pdf for table)*

313. RECORD THE TIME.

INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT INTERVIEW: _____________________________________________

COMMENTS ON SPECIFIC QUESTIONS: _________________________________________

ANY OTHER COMMENTS: ___________________________________________________

SUPERVISOR'S OBSERVATIONS ________________________________________________

EDITOR'S OBSERVATIONS ___________________________________________________