TANZANIA MALARIA INDICATOR SURVEY
HOUSEHOLD QUESTIONNAIRE
UNITED REPUBLIC OF TANZANIA
NATIONAL BUREAU OF STATISTICS
DISTRICT_
WARD_
NAME OF HOUSEHOLD HEAD_
CLUSTER NUMBER_
HOUSEHOLD NUMBER_
FIRST VISIT
INTERVIEWER'S NAME_
RESULT*_
NEXT VISIT
TIME_
INTERVIEWER'S NAME_
RESULT*_
NEXT VISIT
TIME_
INTERVIEWER'S NAME_
RESULT*_
FINAL VISIT
MONTH_
YEAR_
INT. NO._
RESULT*_
TOTAL NUMBER OF VISITS_
TOTAL PERSONS IN HOUSEHOLD_
TOTAL ELIGIBLE WOMEN_
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE_
*RESULT CODES
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 9 (SPECIFY_)
LANGUAGE OF QUESTIONNAIRE** 01
LANGUAGE OF INTERVIEW**_
NATIVE LANGUAGE OF CORRESPONDANT**_
TRANSLATOR USED (YES = 1, NO = 2)_
LANGUAGE OF QUESTIONNAIRE** ENGLISH
** LANGUAGE CODES:
01 ENGLISH
02 KISWAHILI
NUMBER_
Hello. My name is_. I am working with the National Bureau of Statistics. We are conducting a survey about malaria all over 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 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_
RESPONDANT AGREES TO BE INTERVIEWED 1 (CONTINUE)
RESPONDANT 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 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) Just to make sure that I have a complete listing. Are there any other persons such as small
children or infants that are 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.
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
NIECE/NEPHEW BY BLOOD = 09
NIECE/NEPHEW BY MARRIAGE = 10
OTHER RELATIVE = 11
ADOPTED/FOSTER/STEPCHILD = 12
NOT RELATED = 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 LESS THAN ONE YEAR, CODE 00. IF 95 OR MORE, RECORD '95'.
ELIGIBILITY
(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 TO YARD/PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR13 (SKIP TO 105)
PUBLIC TAPS/STANDPIPE 14 (SKIP TO 103)
UNPROTECTED WELL 32 (SKIP TO 103)
UNPROTECTED 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
OTHER (SPECIFY_) 96 (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 105)
PIPED TO NEIGHBOR13 (SKIP TO 105)
PUBLIC TAPS/STANDPIPE 14
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
CART WITH SMALL TANK 71
SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/
IRRIGATION CHANNEL) 81
BOTTLED WATER 91
OTHER (SPECIFY_) 96
103. Where is that water source located?
IN OWN YARD/PLOT 2 (SKIP TO 105)
ELSEWHERE 3
104. How long does it take to go there, get water, and come back?
DON'T KNOW 998
105 (3). 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/WASHABLE 22
PIT LATRINE WITH SLAB/NON WASHABLE 23
PIT LATRINE WITHOUT SLAB/OPEN PIT 24
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?
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 03
BIOGAS 04
KEROSENE 05
COAL, LIGNITE 06
CHARCOAL 07
WOOD 08
STRAW/SHRUBS/GRASS 09
AGRICULTURAL CROP 10
ANIMAL DUNG 11
NO FOOD COOKED IN HOUSEHOLD 95
OTHER (SPECIFY_) 96
109. How many rooms in this household are used 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, 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?
g) Pigs
b) OTHER CATTLE_
c) HORSES/DONKEYS/MULES_
d) GOATS_
e) SHEEP_
f) CHICKENS/POULTRY
g) PIGS_
112. Does any member of your 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 OR MORE HECTARES 950
DON'T KNOW 998
114 (5). Does your household have:
a) Electricity?
b) A radio?
c) A television?
d) A non-mobile telephone?
e) A computer?
f) A refrigerator?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
115. 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?
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
119. Does your household have any mosquito nets?
NO 2 (SKIP T0 131)
120. How many mosquito nets does your household have? IF 7 OR MORE NETS, RECORD '7'.
121. ASK THE RESPONDENT TO SHOW YOU ALL THE NETS IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).
NOT OBSERVED 2
121A. IF NET OBSERVED, RECORD ITS COLOR(S). IF NET NOT OBSERVED, ASK: What color is the net?
SOLID WHITE 2
BLUE AND WHITE STRIPED 3
GREEN 4
OTHER (SPECIFY_) 6
122. 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
123. 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.
OLYSET 12
NETPROTECT 13
DURANET 14
OTHER/DON'T NOW BRAND 16
DON'T KNOW TYPE 98
126 (7). 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); or through the shehia (local governement) issued coupon?
YES, ANC 2 (SKIP TO 128)
YES, IMMUNIZATION VISIT 3 (SKIP TO 128)
YES, SNP 4 (SKIP TO 128)
YES, SHEHIA COUPON 5 (SKIP TO 128)
NO 6
127. 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
127A. Did you pay for the net?
NO 2 (SKIP TO 128)
DON'T KNOW 99999998
128. Did anyone sleep under this mosquito net last night?
NO 2 (SKIP TO 129H)
NOT SURE 8 (SKIP TO 129H)
129. Who slept under this mosquito net last night?
LINE NO._
GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
129H. Why not? RECORD ALL MENTIONED.
NO MALARIA NOW B
TOO HOT C
DON'T LIKE SMELL D
FEEL CLOSED IN/AFRAID E
NET TOO OLD/TORN F
NET TOO DIRTY G
NET NOT AVAILABLE LAST NIGHT/NET BEING WASHED H
USUAL USER(S) DID NOT SLEEP HERE LAST NIGHT I
NET TOO SMALL J
SAVING NET FOR LATER K
NO LONGER KILLS/REPELS MOSQ L
OTHER (SPECIFY_) X
DON'T KNOW Z
130. GO BACK TO 121 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 131.
131. OBSERVE MAIN MATERIAL OF THE FLOOR OF THE DWELLING. RECORD OBSERVATION.
DUNG 12
PALM/BAMBOO 22
VINYL OR ASPHALT STRIPS 32
CERAMIC TILES 33
CEMENT/CONCRETE 34
CARPET 35
132. OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING. RECORD OBSERVATION.
GRASS/THATCH/PALM LEAF/MUD 12
PALM/BAMBOO 22
WOOD PLANKS 23
CONCRETE 32
TILES 33
133. OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING. RECORD OBSERVATION.
GRASS 12
CANE/PALM/TRUNKS/BAMBOO 13
STONE WITH MUD 22
WOOD TIMBER 23
STONE WITH LIME/CEMENT 32
SUN-DRIED BRICKS/MUD BRICK 33
BAKED BRICKS 34
CEMENT BLOCKS 35
133A. OBSERVE EAVES OF THE HOUSE. RECORD OBSERVATION.
ALL EAVES OPEN 12
PARTIALLY CLOSED 13
133B. OBSERVE MATERIAL ON EXTERNAL WINDOWS. RECORD OBSERVATION.
BAGS B
WOOD C
IRON/METAL D
SCREENS E
OTHER (SPECIFY_) X
133C. OBSERVE EXTERNAL WINDOWS. RECORD OBSERVATION.
ALL WINDOWS NOT SCREENED 12 (SKIP TO 134)
SOME WINDOWS SCREENED 13
133D. OBERVETYPE OF SCREENING ON EXTERNAL WINDOWS. RECORD OBSERVATION.
OLD BEDNET 12
MINUTES_
INTERVIEWER'S OBSERVATIONS
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ON SPECIFIC QUESTIONS:_
ANY OTHER COMMENTS:_
EDITOR'S OBSERVATIONS_