CENTRAL STATISTICAL OFFICE

IDENTIFICATION

PROVINCE __________

DISTRICT __________

NAME OF HOUSEHOLD HEAD __________

CLUSTER NUMBER ___

HOUSEHOLD NUMBER ___

LARGE CITY/SMALL CITY/TOWN/RURAL

INTERVIEWER VISITS

FIRST VISIT

DATE _____
INTERVIEWER'S NAME __________
RESULT __________

SECOND VISIT

DATE _____
INTERVIEWER'S NAME __________
RESULT __________

THIRD VISIT

DATE _____
INTERVIEWER'S NAME __________
RESULT __________

FINAL VISIT

DAY ___
MONTH __________
YEAR _____
ID NUMBER ___
RESULT __________

NEXT VISIT

DATE _____
TIME _____

TOTAL NUMBER OF VISITS ___

*RESULT__

TOTAL PERSONS IN HOUSEHOLD ___

TOTAL ELIGIBLE WOMEN ___

TOTAL ELIGIBLE MEN ___

LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___

LANGUAGE OF QUESTIONNAIRE:

LANGUAGE USED FOR INTERVIEW:

TRANSLATOR USED:

SUPERVISOR

NAME __________
DATE _____

FIELD EDITOR

NAME __________
DATE _____

OFFICE EDITOR ___

KEYED BY ___

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 NAMES, RELATIONSHIPS, AND SEX ASK QUESTIONS 2A-2C TO BE SURE THAT THE LISTING IS COMPLETE. THEN ASK APPROPRIATE QUESTIONS IN COLUMNS 5-35 FOR EACH MEMBER OF THE HOUSEHOLD.

3) RELATIONSHIP TO HEAD OF HOUSEHOLD

What is the relationship of (NAME) to the head of the household?

SEE CODES BELOW

CODES FOR QUESTION 3
RELATIONSHIP TO HEAD OF HOUSEHOLD:

4) SEX

Is (NAME) male or female?

5) RESIDENCE

Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE

How old is (NAME)?

8) IF AGE 15 OR OLDER: MARITAL STATUS

What is (NAME'S) current marital status?

SEE CODES BELOW

CODES FOR QUESTION 8

9) ELIGIBILITY

LINE NUMBER OF ALL WOMEN AGE 15-49

10) LINE NUMBER OF WOMEN SELECTED FOR DOMESTIC VIOLENCE MODULE USING QUESTION 38

11) LINE NUMBER OF ALL MEN AGE 15-54

12) LINE NUMBER OF ALL CHILDREN AGE 0-5

13) SICK PERSON: IF AGE 18-59

Has (NAME) been very sick for at least 3 months during the past 12 months? By very sick I mean (NAME) was too sick to work or do normal activities around the house for at least 3 months during the past 12 months?

PARENTAL SURVIVORSHIP, RESIDENCE, AND HEALTH STATUS: FOR PERSONS AGE 0-17 YEARS

14.Is (NAME)'s biological mother alive?

15) IF ALIVE

Does (NAME)'s biological mother live in this household?

IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER

RECORD '00' IF NOT LISTED IN SCHEDULE LISTED

16) FOR MOTHERS NOT IN HOUSEHOLD ASK:

Has (NAME)'s biological mother been very sick for at least 3 months during the past 12 months, that is, too sick to work or do normal activities around the house for at least 3 months during the past 12 months?

17) Is (NAME)'s biological father alive?

18) IF ALIVE

Does (NAME)'s biological father live in this household?

IF YES: What is his name?
RECORD FATHER'S LINE NUMBER

RECORD '00' IF NOT LISTED IN SCHEDULE

19) FOR FATHERS NOT IN HOUSEHOLD ASK:

Has (NAME)'s biological father been very sick for at least 3 months during the past 12 months, that is, too sick to work or do normal activities around the house for at least 3 months during the past 12 months?

20) CHECK QUESTIONS 13-19
RECORD LINE NUMBER FOR ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED (QUESTION 14 AND QUESTION 17) OR IS VERY SICK (QUESTION 16 AND QUESTION 19)

21) CHECK QUESTION 14 AND QUESTION 17

IF BOTH YES (BOTH ALIVE) CIRCLE '1'

IF ELSE, CIRCLE '2'

22) NATURAL BROTHERS AND SISTERS AGE 0-17 YEARS: FOR PERSONS AGE 0-17 YEARS

Does (NAME) have any natural brothers under the age of 18? (By natural brothers, I mean brothers who have the same biological mother and the same father)

23) Do all of (NAME)'s natural brothers under the age of 18 live in this household?

24) Does (NAME) have any natural sisters under the age of 18? (By natural sisters I mean sisters who have the same biological mother and the same father)

25) Do all of (NAME)'s natural sisters under the age of 18 live in this household?

EDUCATION: IF AGE 3 YEARS OR OLDER

26) Has (NAME) ever attended school?

27) What is the highest level of school (NAME) has attended?

What is the highest grade (NAME) completed at that level?

SEE CODES BELOW.

IF AGE 3-24 YEARS

28) Did (NAME) attend school at any time during the current 2005 school year?

29) During this school year, what level and grade [is/was] (NAME) attending?

30) Did (NAME) attend school at any time during the previous school year, that is, in 2004?

31) During that school year, what level and grade did (NAME) attend?

CODES FOR QUESTIONS 27, 29 AND 31
EDUCATION LEVEL:

EDUCATION GRADE:

BASIC MATERIAL NEEDS: IF AGE 3-17 YEARS

32) Is there something that (NAME) can use to cover (himself/herself) when (he/she) is sleeping?

33) Does (NAME) have a pair of shoes?

34) Does (NAME) have at least two sets of clothing?

35) BIRTH REGISTRATION: IF AGE 0-4

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

TICK HERE IF ADDITIONAL QUESTIONNAIRE USED ___

PROBE TO IDENTIFY ADDITIONAL HOUSEHOLD RESIDENTS

.

Just to make sure that I have a complete household listing:

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

2B) In addition, are there any other people who may not be members of your family, such as domestic servants or friends who usually live here?

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

TABLE FOR SELECTION OF WOMEN FOR THE DOMESTIC VIOLENCE QUESTIONS

38) LOOK AT THE LAST DIGIT OF THE QUESTIONNAIRE NUMBER ON THE COVER PAGE. THIS IS THE NUMBER OF THE ROW YOU SHOULD GO TO.
CHECK THE TOTAL NUMBER OF ELIGIBLE WOMEN ON THE COVER SHEET OF THE HOUSEHOLD QUESTIONNAIRE. THIS IS THE NUMBER OF THE COLUMN YOU SHOULD GO TO.
FIND THE BOX WHERE THE ROW AND THE COLUMN MEET AND CIRCLE THE NUMBER THAT APPEARS IN THE BOX. THIS NUMBER IS USED TO IDENTIFY WHETHER THE FIRST ('1'), SECOND ('2'), THIRD ('3'), ETC. ELIGIBLE WOMAN LISTED IN THE HOUSEHOLD SCHEDULE WILL BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
CIRCLE THE LINE NUMBER FOR THIS WOMAN IN COLUMN 10.

FOR EXAMPLE, IF THE QUESTIONNAIRE NUMBER IS '36716', GO TO ROW '6'.
IF THERE ARE THREE ELIGIBLE WOMEN IN THE HOUSEHOLD, GO TO COLUMN '3'.
FIND THE BOX WHERE ROW '6' AND COLUMN '3' MEET. THE NUMBER IN THAT BOX ('2') INDICATES THAT THE SECOND ELIGIBLE WOMAN IN THE HOUSEHOLD LISTING SHOULD BE ASKED THE DOMESTIC VIOLENCE QUESTIONS.
SUPPOSE THE LINE NUMBERS OF THE THREE WOMEN ARE '02', '03', AND '07'. THE WOMAN TO BE ASKED THE DOMESTIC VIOLENCE QUESTIONS IS THE SECOND ONE, I.E., THE WOMAN ON LINE '03'.

LAST DIGIT OF THE QUESTIONNAIRE NUMBER (ROW)

TOTAL NUMBER OF ELIGIBLE WOMAN IN HOUSEHOLD (COLUMN)

101) What is the main source of drinking and cooking water for members of your household?

102) What is the main source of water used by your household for other purposes such as hand washing or bathing?

103) Where is the water source located?

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

105) Who usually goes to this source to fetch the water for your household?

106) Do you treat your water to make it more safe to drink?

107) What do you usually do to the water to make it more safe to drink?
Anything else?
RECORD ALL MENTIONED.

108) What kind of toilet facility do members of your household usually use?

109) Do you share this facility with other households?

110) Including this household, how many households use this toilet facility?

111) Does your dwelling unit/household have:

ELECTRICITY

RADIO

TELEVISION

MOBILE TELEPHONE

NON-MOBILE TELEPHONE

REFRIGERATOR

112) What type of fuel does your household mainly use for cooking?

113) In this household, is food cooked on a stove or an open fire?
PROBE FOR TYPE.

114) Is the cooking usually done in the same building where people sleep, in a separate building, or outdoors?

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

116) TYPE OF DWELLING UNIT
RECORD OBSERVATION.

117) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION.

118) MAIN MATERIAL OF THE ROOF
RECORD OBSERVATION.

119) MAIN MATERIAL OF THE WALLS
RECORD OBSERVATION.

120) TYPE OF WINDOWS
RECORD OBSERVATION.

121) How many rooms in this household are used for sleeping?

122) Does any member of this household own:

123) Do any members of this household have access to use land for agricultural purposes?

124) How many acres of land are used by household members for agricultural purposes?
IF MORE THAN 97, ENTER '97'.
IF UNKNOWN, ENTER '98'.

125) Does this household own any livestock, herds, or farm animals?

126) How many of the following animals does this household have?
IF NONE, ENTER '00'.
IF MORE THAN 97, ENTER '97'.
IF UNKNOWN, ENTER '98'.

127) Does any member of this household have a bank account?

128) During the past 12 months, has anyone sprayed the interior walls of your dwelling against mosquitoes?
IF NOT SPRAYED, RECORD 95.
IF YES: How many months ago was the house sprayed?
RECORD '00' IF LESS THAN ONE MONTH.

129) Who sprayed the house?

130) Does your household have any mosquito nets that can be used while sleeping?

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

132) ASK THE RESPONDENT TO SHOW YOU THE NET(S) IN THE HOUSEHOLD. IF MORE THAN 3 NETS, USE ADDITIONAL QUESTIONNAIRE(S).

133) How many months ago did your household obtain the mosquito net?
IF LESS THAN ONE MONTH, RECORD '00'.

134) What type of mosquito net do you have?

135) When you got the net, was it treated with an insecticide to kill or repel mosquitos?

136) Since you got the mosquito net, was it ever soaked or dipped in a liquid or chemical to repel mosquitos?

137) How many months ago was the net last soaked or dipped?
IF LESS THAN ONE MONTH, RECORD '00'.

138) Did anyone sleep under this mosquito net last night?

139) Who slept under this mosquito net last night?
RECORD THE RESPECTIVE LINE NUMBER FROM THE HOUSEHOLD SCHEDULE.

140) GO BACK TO 132 FOR NEXT NET; OR, IF NO MORE NETS, GO TO 201.

SECTION 2: SUPPORT FOR SICK PEOPLE

201) CHECK QUESTION 36 IN HOUSEHOLD SCHEDULE AND RECORD NUMBER OF CHRONICALLY SICK HOUSEHOLD MEMBERS AGE 18-59.

202) ENTER IN THE TABLE THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-59, BEGINNING WITH THE FIRST SICK PERSON LISTED IN THE HOUSEHOLD SCHEDULE. ASK THE QUESTIONS ABOUT ALL OF THESE PEOPLE. IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S).

203) LINE NUMBER AND NAME FROM COLUMNS 1 AND 2 OF THE HOUSEHOLD SCHEDULE

204) You told me that in your household, (NAME OF EACH SICK PERSON IN 203) has(have) been very sick for at least three of the past 12 months. I would like to ask you about any formal, organized help or support that your household may have received for [that/each of those] person(s) for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

205) Now I would like to ask you about the support you received for (NAME). In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

206) Did your household receive any of this support at least once a month while (NAME) was sick?

207) In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did not have to pay?

208) Did your household receive any of this support in the past 30 days?

209) In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

210) Did your household receive any of this support in the past 30 days?

211) In the last 12 months, has your household received any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

212) Did your household receive any of this support in the past 30 days?

213) Now I would like to ask about health problems (NAME) may have recently had. In the last 30 days, has (NAME) had severe pain, mild pain, or no pain at all?

214) When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

215) In the last 30 days, did (NAME) suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Was this problem (were any of these problems) ever severe?

216) Was (NAME) able to reduce or stop the (nausea/coughing/diarrhea/constipation) most of the time, some of the time, or not at all?

217) GO BACK TO 205 IN NEXT COLUMN; OR, IF NO MORE SICK PEOPLE, GO TO 301.

SECTION 3: SUPPORT FOR PERSONS WHO HAVE DIED

301) Now I would like to ask you a few more questions about your household. Think back over the past 12 months. Has any usual member of your household died in the last 12 months?

302) How many household members died in the last 12 months?

303) ASK 304-322 FOR ONE PERSON AT A TIME. IF MORE THAN 3 PEOPLE HAVE DIED, USE ADDITIONAL QUESTIONNAIRE.

304) What was the name of the person who died (most recently/before him/her)?

305) Was (NAME) male or female?

306) How old was (NAME) when (he/she) died?

307) Was (NAME) very sick for at least three of the 12 months before (he/she) died? By very sick, I mean that (NAME) was too sick to work or do normal activities around the house for at least three months.

308) CHECK 306: AGE OF PERSON AT DEATH

309) I would like to ask you about any formal, organized help or support that your household may have received for [NAME] before (he/she) died, for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

310) In the last 12 months, did your household receive any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

311) Did your household receive any of this support at least once a month while (NAME) was sick?

312) In the last 12 months, did your household receive any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support for which you did not have to pay?

313) Did your household receive any of this support in the last 30 days before (NAME)'s death?

314) In the last 12 months, did your household receive any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

315) Did your household receive any of this support in the last 30 days before (NAME)'s death?

316) In the last 12 months, did your household receive any social support for (NAME), such as help in household work, training for a caregiver, or legal services, for which you did not have to pay?

317) Did your household receive any of this support in the last 30 days before (NAME)'s death?

318) Now I would like to ask about health problems (NAME) may have recently had. In the 30 days before (NAME) died, did he/she have severe pain, mild pain, or no pain at all.

319) When (NAME) was in pain, was he/she able to reduce or stop the pain most of the time, some of the time, or not at all?

320) In the 30 days before (NAME) died, did he/she suffer from nausea, coughing, diarrhea, or constipation?
IF YES: Was this problem (were any of these problems) ever severe?

321) Was (NAME) able to reduce or stop the (nausea/coughing/diarrhea/constipation) most of the time, some of the time, or not at all?

322) GO BACK TO 304 IN NEXT COLUMN; OR, IF NO MORE PEOPLE HAVE DIED, GO TO 401.

SECTION 4: SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN

401) CHECK COLUMN 7 IN THE HOUSEHOLD SCHEDULE: ANY CHILD AGE 0-17?

402) CHECK QUESTION 36 IN HOUSEHOLD QUESTIONNAIRE: ANY VERY SICK ADULTS 18-59?

403) CHECK 306 IN SECTION 3: ANY ADULT AGE 18-59 WHO DIED IN PAST 12 MONTHS?

404) CHECK QUESTION 37 IN HOUSEHOLD SCHEDULE: ANY CHILD WHOSE MOTHER AND/OR FATHER HAS DIED OR WHOSE MOTHER AND/OR FATHER IS NOT LIVING IN THE HOUSEHOLD AND IS SICK?

405) RECORD NAMES, LINE NUMBERS AND AGES OF CHILDREN AS APPRORIATE BEGINNING WITH THE FIRST CHILD AND CONTINUING IN THE ORDER IN WHICH THE CHILDREN ARE LISTED IN THE SCHEDULE OR IN COLUMN 20. IF MORE THAN 8 CHILDREN USE AN ADDITIONAL QUESTIONNAIRE.

406) I would like to ask you about any formal, organized help or support that your household may have received for (NAME OF EACH CHILD IN 405) and for which you did not have to pay. By formal, organized support I mean help provided by someone working for a program. This program could be government, private, religious, charity, or community based.

ASK THE CARE AND SUPPORT QUESTIONS FOR EACH CHILD LISTED IN QUESTION 405, BEGINNING WITH THE CHILD LISTED IN THE FIRST COLUMN.

407) Now I would like to ask you about the support your household received for (NAME).

In the last 12 months, has your household received any medical support for (NAME), such as medical care, supplies or medicine, for which you did not have to pay?

408) In the last 12 months, has your household received any emotional or psychological support for (NAME), such as companionship, counseling from a trained counselor, or spiritual support, which you received at home and for which you did not have to pay?

409) Did your household receive any of this support in the past 3 months?

410) In the last 12 months, has your household received any material support for (NAME), such as clothing, food, or financial support, for which you did not have to pay?

411) Did your household receive any of this support in the past 3 months?

412) In the last 12 months, has your household received any social support for (NAME) such as help in household work, training for a caregiver, or legal services for which you did not have to pay?

413) Did your household receive any of this support in the past 3 months?

414) CHECK 405: AGE OF CHILD

415) In the last 12 months, has your household received any support for (NAME'S) schooling, such as allowance, free admission, books or supplies, for which you did not have to pay?

416) GO BACK TO 407 IN NEXT COLUMN IN THIS QUESTIONNAIRE, OR IN THE FIRST COLUMN OF THE ADDITIONAL QUESTIONNAIRE(S); OR, IF NO MORE CHILDREN, CONTINUE WITH INDIVIDUAL INTERVIEW WITH ELIGIBLE RESPONDENT.

SECTION 5: WEIGHT AND HEIGHT MEASUREMENT - ALL CHILDREN UNDER AGE 5 HEMOGLOBIN MEASUREMENT - CHILDREN 6-60 MONTHS

CHECK COLUMN (12): RECORD THE LINE NUMBER, NAME AND AGE OF ALL CHILDREN AGE 0-60 MONTHS.

FOR CHILDREN NOT INCLUDED IN ANY BIRTH HISTORY, ASK DAY, MONTH AND YEAR. FOR ALL OTHER CHILDREN, COMPARE MONTH AND YEAR FROM 215 IN MOTHER'S BIRTH HISTORY AND ASK DAY.

BEFORE CONDUCTING ANEMIA TESTING, OBTAIN CONSENT FROM PARENT, GUARDIAN, OR OTHER RESPONSIBLE ADULT.

501) CHILDREN UNDER AGE 5: LINE NUMBER FROM COLUMN (12)

502) NAME FROM COLUMN (2)

503) AGE FROM COLUMN (7)

504) What is (NAME'S) date of birth?

505) WEIGHT AND HEIGHT MEASUREMENT OF CHILDREN BORN IN 2000 OR LATER: WEIGHT (KILOGRAMS)

506) HEIGHT (CENTIMETERS)

507) MEASURED LYING DOWN OR STANDING UP

508) RESULT

TICK HERE IF CONTINUATION SHEET USED ___

CONSENT STATEMENT

As part of this survey, we are trying to find out more about anaemia, that is, low blood levels, in men, women, and children.

To know more about this problem in Zimbabwe, we are asking in this survey that young children all over the country take a test for low blood levels. We would like (NAME OF CHILD(REN) BORN IN 2000 OR LATER, AND AT LEAST 6 MONTHS OF AGE) to take part in this test by giving a few drops of blood from his (her) finger or heel.

The test uses clean and completely safe equipment that is used only once and then thrown away. The blood will be tested with new equipment. The result(s) for (NAME OF CHILD[REN]) will be given to you right after the test is done.

We will not tell anyone else the results of the test.

Do you have any questions?

You can say yes or you can say no; it is up to you. If you say yes, it will help the country to develop programs to fight the problem of anaemia.

Do you agree that (NAME) may give blood for the anaemia test?
CIRCLE CODE AND SIGN.

509) HEMOGLOBIN MEASUREMENT OF CHILDREN 6-60 MONTHS: RECORD NAME OF PARENT/RESPONSIBLE ADULT

510) LINE NUMBER OF PARENT/RESPONSIBLE ADULT.
RECORD '00' IF NOT LISTED IN HOUSEHOLD SCHEDULE

511) READ CONSENT STATEMENT TO PARENT/RESPONSIBLE ADULT.
CIRCLE CODE (AND SIGN)

512) HEMOGLOBIN LEVEL (G/DL)

513) RESULT

514) CHECK 512: NUMBER OF CHILDREN WITH HEMOGLOBIN LEVEL BELOW 7 G/DL.

515) We detected a low level of hemoglobin in the blood of (NAME OF CHILD(REN)). This indicates that (NAME OF CHILD(REN)) have developed severe anemia, which is a serious health problem. We would like to inform the clinic at __________ about the condition of (NAME OF CHILD(REN)). This will assist you in obtaining appropriate treatment for the condition. Do you agree that the information about the level of hemoglobin in the blood of (NAME OF CHILD(REN)) may be given to the clinic?

INTERVIEWER'S OBSERVATIONS

TO BE FILLED IN AFTER COMPLETING INTERVIEW

COMMENTS ABOUT RESPONDENT:

COMMENTS ON SPECIFIC QUESTIONS:

ANY OTHER COMMENTS:

SUPERVISOR'S OBSERVATIONS

NAME OF THE SUPERVISOR: __________

DATE: _____