2018-19 UGANDA MALARIA INDICATOR SURVEY HOUSEHOLD QUESTIONNAIRE
EA NAME
NAME OF HOUSEHOLD HEAD
CLUSTER NUMBER
HOUSEHOLD NUMBER
FIRST VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT:
DATE
TIME
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NEXT VISIT:
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
FINAL VISIT:
DAY
MONTH
YEAR
INT. NO.
RESULT*
TOTAL NUMBER OF VISITS__
*RESULT CODES
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 PERSONS IN HOUSEHOLD__
TOTAL ELIGIBLE WOMEN__
TOTAL ELIGIBLE CHILDREN__
LINE NO. OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE__
LANGUAGE OF QUESTIONNAIRE*
**LANGUAGE CODES
02 LUGANDA
03 LUO
04 LUGBARA
05 ATESO
06 RUNYANKOLE/ RUKIGA
07 RUNYORO/ RUTORO
96 OTHER__(SPECIFY)
LANGUAGE OF INTERVIEW**__
NATIVE LANGUAGE OF RESPONDENT**__
TRANSLATOR USED
2 NO
SUPERVISOR
NAME__
NUMBER____
Hello. My name is ___. I am working with the Ministry of Health/ UBOS. We are conducting a survey about malaria all over Uganda. 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 a question you don't want to answer, just let me know and I will go on to the next question or you can just 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 INTERVIEW)
RECORD THE TIME.
HOURS__
MINUTES__
1) LINE NO.
2) USUAL RESIDENTS AND VISITORS
Please give me the first 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 people such as small children or infants that we have not listed?
NO (CONTINUE)
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 (CONTINUE)
2C) Are there any guests or temporary visitors staying here, or anyone else who stayed here last night, who have not been listed?
NO (CONTINUE)
3) RELATIONSHIP TO THE HEAD OF HOUSEHOLD
What is the relationship of (NAME) to the head of the household?
SEE CODES BELOW.
CODES FOR Q.3: RELATIONSHIP TO HEAD OF HOUSEHOLD
02= WIFE OR HUSBAND
03= SON OR DAUGHTER
04= SON-IN-LAW OR DAUGHTER-IN-LAW
05= GRANDCHILD
06= PARENT
07= PARENT-IN-LAW
08= BROTHER OR SISTER
09= OTHER RELATIVE
10= ADOPTED/ FOSTER/ STEPCHILD
11= NOT RELATED
98= DON'T KNOW
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
IF 95 OR MORE, RECORD '95'.
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 TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/ STANDPIPE 14 (SKIP TO 103)
UNPROTECTED WELL 32 (SKIP TO 103)
UNPROTECTED SPRING 42 (SKIP TO 103)
TANKER TRUCK 61 (SKIP TO 103)
BICYCLE WITH JERRY CANS 71 (SKIP TO 103)
SURFACE WATER (RIVER/ DAM/ LAKE/ POND/ STREAM/ CANAL/ IRRIGATION CHANNEL) 81 (SKIP TO 103)
BOTTLED WATER 91
SACHET WATER 92
102) What is the main source of water used by your dwelling for other purposes such as cooking and handwashing?
PIPED INTO YARD/ PLOT 12 (SKIP TO 105)
PIPED TO NEIGHBOR 13 (SKIP TO 105)
PUBLIC TAP/ STANDPIPE 14
UNPROTECTED WELL 32
UNPROTECTED SPRING 42
TANKER TRUCK 61
BICYCLE WITH JERRY CANS 71
SURFACE WATER (RIVER/ DAM/ LAKE/ POND/ STREAM/ CANAL/ IRRIGATION CHANNEL) 81
BOTTLED WATER 91
SACHET WATER 92
103) Where is that water source located?
IN OWN YARD/ PLOT (SKIP TO 105)
ELSEWHERE 3
104) How long does it take 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)
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/ CYLINDER GAS 02
BIOGAS 04
KEROSENE 05
CHARCOAL 07
WOOD 08
STRAWS/ SHRUBS/ GRASS 09
AGRICULTURAL CROP RESIDUE 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'.
112) Does any member of this household own any agricultural land?
NO 2 (SKIP TO 114)
113) How many acres of agricultural land do members of this household own?
IF 95 OR MORE HECTARES, CIRCLE '950'.
IF 95 OR MORE ACRES, RECORD IN HECTARES.
IF 95 OR MORE POLES, RECORD IN ACRES.
ACRES 2 __.__
POLES 3 __.__
95 OR MORE HECTARES 950
DON'T 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 this household own:
NO 2
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
117) At any time in the last 12 months, has anyone come into your dwelling to spray the interior against mosquitoes?
NO 2 (SKIP TO 118)
DON'T KNOW 8 (SKIP TO 118)
117A) How many months ago was the dwelling last sprayed?
IF LESS THAN 1 MONTH, RECORD '00'.
117B) Who sprayed the dwelling?
PRIVATE COMPANY B
NONGOVERNMENTAL ORGANIZATION (NGO) C
OTHER__(SPECIFY) X
DON'T KNOW Z
117C) Did you pay for your dwelling to be sprayed?
NO 2
DON'T KNOW 8
118) Is there a community worker, community medicine distributer (CMD), or a village health team (VHT) member who distributes malaria medicines in your village or community?
NO 2 (SKIP TO 119)
DON'T KNOW 8 (SKIP TO 119)
118A) Does the community health worker currently have malaria medicines available?
NO 2
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'.
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
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.
PERMANET 3.0 12
DURANET 13
INTERCEPTOR 14
NETPROTECT 15
OLYSET 16
OLYSET PLUS 17
DAWA PLUS 18
ICONLIFE 19
YORKOOL 20
MAGNET 21
LLIN DK BRAND 22
OTHER LLIN__(SPECIFY) 23
OTHER BRAND 96
DK BRAND 98
126) Did you get the net through a mass distribution, during an antenatal care visit, or during an immunization?
YES, ANC 2 (SKIP TO 128)
YES, IMMUNIZATION VISIT 3 (SKIP TO 128)
NO 4
127) Where did you get the net?
GOVERNMENT HEALTH FACILITY 12
HEALTH FACILITY 22
PHARMACY 32
HAWKER 42
CHW 43
RELIGIOUS INSTITUTION 44
DON'T KNOW 98
128) Did anyone sleep under this mosquito net last night?
NO 2
NOT SURE 8 (SKIP TO 130)
128A) What are some of the reasons why this net was not used?
RECORD ALL MENTIONED.
DON'T LIKE SMELL B (SKIP TO 130)
NO MOSQUITOES C (SKIP TO 130)
NET TOO OLD/ MANY HOLES D (SKIP TO 130)
UNABLE TO HANG E (SKIP TO 130)
NO PLACE TO HANG F (SKIP TO 130)
CHEMICALS IN NET NOT SAFE G (SKIP TO 130)
SAVING FOR RAINY SEASON H (SKIP TO 130)
SAVING TO REPLACE OTHER NET I (SKIP TO 130)
MATERIAL TOO HARD/ ROUGH J (SKIP TO 130)
USUAL USER DIDN'T SLEEP HERE K (SKIP TO 130)
OTHER__(SPECIFY) X (SKIP TO 130)
DON'T KNOW Z (SKIP TO 130)
129) Who slept under this mosquito net last night?
RECORD THE PERSON'S NAME AND LINE NUMBER FROM HOUSEHOLD SCHEDULE.
LINE NO.__
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
CONCRETE 32
CERAMIC TILES 33
CEMENT 34
CARPET 35
STONES 36
BRICKS 37
132) OBSERVE MAIN MATERIAL OF THE ROOF OF THE DWELLING.
RECORD OBSERVATION.
THATCH/ PALM LEAF 12
MUD 13
TINS 22
WOOD PLANKS 23
CARDBOARD 24
TARPAULIN 25
WOOD 32
ASBESTOS 33
TILES 34
CONCRETE 35
ROOFING SHINGLES 36
133) OBSERVE MAIN MATERIAL OF THE EXTERIOR WALLS OF THE DWELLING.
RECORD OBSERVATION.
THATCHED/ STRAW 12
DIRT 13
STONE WITH MUD 22
UNBURNT BRICKS WITH MUD 23
PLYWOOD 24
CARDBOARD 25
REUSED WOOD 26
UNBURNT BRICKS WITH PLASTER 27
BURNT BRICKS WITH MUD 28
STONE WITH LIME/ CEMENT 32
BURNT BRICKS WITH CEMENT 33
CEMENT BLOCKS 34
UNBURNT BRICKS WITH CEMENT 35
WOOD PLANKS/ SHINGLES 36
TO BE FILLED IN AFTER COMPLETING INTERVIEW
COMMENTS ABOUT INTERVIEW:
COMMENTS ON SPECIFIC QUESTIONS:
ANY OTHER COMMENTS:
SUPERVISOR'S OBSERVATIONS