SECTION M: NON-FOOD EXPENDITURES â Past twelve months. SECTION B: ...... From which country did these in-kind remittan
CONFIDENTIAL PUBLIC DISCLOSURE AUTHORIZED
United Republic of Tanzania National Bureau of Statistics
NATIONAL PANEL SURVEY (NPS 2010/2011) This information is collected under the Act of the Parliament (Act No. 1 of 2002) THIS INFORMATION IS STRICTLY CONFIDENTIAL AND IS TO BE USED FOR STATISTICAL PURPOSES ONLY.
HOUSEHOLD AND INDIVIDUAL QUESTIONNAIRE SECTION A-1: HOUSEHOLD IDENTIFICATION MARK BOX WITH AN 'X' AND NUMBER FORMS BELOW IF YOU USE MORE THAN THIS SINGLE FORM TO COLLECT INFORMATION FROM THIS HOUSEHOLD. IF SO, BE SURE TO MARK IN THE SAME WAY THE OTHER FORMS USED FOR THIS HOUSEHOLD
CODE
1. REGION: 2. DISTRICT 3. WARD 4. VILLAGE/ENUMERATION AREA 5. KITONGOJI OR MTAA NAME 7. HOUSEHOLD ID (FROM LIST) :
FORM ____ OF ____ TOTAL
8. NAME OF HOUSEHOLD HEAD: SINGLE CHEWA. HOUSE. . 1 TONGA. . . . 1.10
NONE . To . .be. compiled. . . 1 GRASS . . . . . 1
GRASS. . . . . 1
9. NAME OF HOUSEHOLD HEAD FROM NPS YEAR 1: 10. FULL HOUSEHOLD IDENTIFICATION FROM NPS YEAR 1: 11. IS THIS HOUSEHOLD:
ORIGINAL HOUSEHOLD IN SAME LOCATION..1 ►14 ORIGINAL HOUSEHOLD IN NEW LOCATION...2 ►14 SPLIT-OFF HOUSEHOLD..................3
12. NAME OF TRACKING TARGET: 13. ROSTER ID OF TRACKING TARGET FROM NPS YEAR 1:
14.
DESCRIPTION OF LOCATION OF HOUSEHOLD - INCLUDE ANY IDENTIFYING CHARACTERISTICS OF DWELLING, NAME OF NEIGHBOURING HOUSEHOLDS & KEY PERMANENT CONTACTS, PHONE NUMBER (IF ANY). SKETCH MAP OF DWELLING LOCATION IN SPACE AT PAGE BOTTOM.
SECTION A-2: SURVEY STAFF DETAILS OBSERVATIONS ON THE INTERVIEW RECORD GENERAL NOTES ABOUT THE INTERVIEW AND RECORD ANY SPECIAL INFORMATION THAT WILL BE HELPFUL FOR SUPERVISORS AND THE ANALYSIS OF THIS QUESTIONNAIRE.
15. NAME OF ENUMERATOR:
16. ENUMERATOR CODE: 17. TIME INTERVIEW START
:
18. DATE OF INTERVIEW:
/
/
/
/
/
/
/
/
(ENUMERATOR ►NEXT PAGE)
19. NAME OF FIELD SUPERVISOR: 20. FIELD SUPERVISOR CODE: 21. DATE OF QUESTIONNAIRE INSPECTION: 22. NAME OF DATA ENTRY CLERK: 23. DATA ENTRY CLERK CODE: 24. DATE OF DATA ENTRY: 25. 2ND DATA ENTRY CLERK CODE: 26. DATE OF 2ND DATA ENTRY:
A STAFF DETAILS - 2
INTRODUCTION TO THE HOUSEHOLD TO BE INTERVIEWED CONVEY THE FOLLOWING INFORMATION TO THE RESPONDENT: In 2008/2009, the National Bureau of Statistics in Tanzania selected over one hundred households in each region of the country to ask them q uestions about how they were living. The responses which were provided by the households to these questions were used to help the government of Tanzania do a better j ob in meeting the needs of all Tanzanians. NEW HOUSEHOLDS IN MOROGORO, DAR ES SALAAM AND PWANI: Now in 2010/2011 we are expanding these efforts. Your household was selected as one of those to which the questions will be asked this time. You were not selected for any sp ecific reason. Simply your name appeared on a list of all of the households in this area, and your name was chosen randomly. NPS HOUSEHOLDS: Now in 2010/2011, we are returning the these same households to see how things are progressing. SPLIT-OFF HOUSEHOLDS: At the time of that survey, one of your household members was living in a selected household, and we would like to see how t hings are progressing and how they, and the rest of their new household, are living now.
ALL: I would like to ask the questions in this form to you as head of household or spouse of the head. I will also need to ask qu estions to other members of your household, as well as weigh and measure the height of everyone who lives in your household. These questions will take several hours to complete. All o f your answers will be held in confidence. The answers which you and the members of your household might give me will only be used by the NBS or under its supervision. Before I start, do you have any questions or is there anything which I have said on which you would like any further clarific ation? May I proceed with interviewing you and members of your household?
TABLE OF CONTENTS To be compiled.
SECTION A-1: HOUSEHOLD IDENTIFICATION SECTION A-2: SURVEY STAFF DETAILS SECTION B: HOUSEHOLD MEMBER ROSTER
SECTION L: NON-FOOD EXPENDITURES – Past one week & one month SECTION M: NON-FOOD EXPENDITURES – Past twelve months SECTION N: HOUSEHOLD ASSETS
SECTION C: EDUCATION
SECTION O: ASSISTANCE AND GROUPS
SECTION D: HEALTH
SECTION P: CREDIT
SECTION E: LABOUR
SECTION Q: FINANCE
SECTION F: FOOD OUTSIDE THE HOUSEHOLD
SECTION R: RECENT SHOCKS TO HOUSEHOLD WELFARE
SECTION G. SUBJECTIVE WELFARE
SECTION S: DEATHS IN HOUSEHOLD
SECTION H. GOVERNANCE
SECTION V-1: HOUSEHOLD RECONTACT INFORMATION
SECTION I: FOOD SECURITY
SECTION V-2: FILTER QUESTIONS
SECTION J: HOUSING, WATER AND SANITATION
SECTION U: ANTHROPOMETRY
SECTION K: CONSUMPTION OF FOOD OVER PAST ONE WEEK
SINGLE CHEWA. HOUSE. . 1 TONGA. . . . 1.10
NONE . . . . . . 1
GRASS . . . . . 1
GRASS. . . . . 1
A STAFF DETAILS - 3
SECTION B: HOUSEHOLD MEMBER ROSTER IN ORDER TO MAKE A COMPREHENSIVE LIST OF HOUSEHOLD MEMBERS, USE THE FOLLOWING PROBE QUESTIONS: FIRST, ASK NAMES OF ALL THE MEMBERS OF YOUR IMMEDIATE (NUCLEAR) FAMILY WHO NORMALLY LIVE AND EAT THEIR MEALS TOGETHER HERE. WRITE DOWN NAMES, SEX, AND RELATIONSHIP TO HOUSEHOLD HEAD FILL IN QUESTIONS 1 TO 6 THEN, ASK NAMES OF ANY OTHER PERSONS RELATED TO YOU OR OTHER HOUSEHOLD MEMBERS WHO NORMALLY LIVE AND EAT THEIR MEALS TOGETHER HERE. FILL IN QUESTIONS 1 TO 6 ALSO ASK OTHER PERSONS NOT HERE NOW WHO NORMALLY LIVE AND EAT THEIR MEALS HERE? FOR EXAMPLE, HOUSEHOLD MEMBERS STUDYING ELSEWHERE OR TRAVELING. FILL IN QUESTIONS 1 TO 6. THEN, ASK NAMES OF ANY OTHER PERSONS NOT RELATED TO YOU OR OTHER HOUSEHOLD MEMBERS, BUT WHO NORMALLY LIVE AND EAT THEIR MEALS TOGETHER HERE, SUCH AS LIVE-IN SERVANTS. FILL IN QUESTIONS 1 TO 6 IF MORE THAN 12 INDIVIDUALS, USE SECOND QUESTIONNAIRE. MAKE SURE TO MARK BOX ON FIRST PAGE OF BOTH QUESTIONNAIRES.
1.
2.
3.
4.
NAME
Sex
In what month and year was [NAME] born?
How old is [NAME]?
I N D I V I D U A L
LIST HOUSEHOLD HEAD ON LINE 1. MAKE A COMPLETE LIST OF ALL INDIVIDUALS WHO NORMALLY LIVE AND EAT THEIR MEALS TOGETHER IN THIS HOUSEHOLD, STARTING WITH THE HEAD OF HOUSEHOLD.
I D
(CONFIRM THAT HOUSEHOLD HEAD HERE IS SAME AS HOUSEHOLD HEAD LISTED ON COVER.)
PUT "99" IF DON'T KNOW
M..1 F..2
YEAR
MONTH
5.
6.
What is [NAME]'s IF THIS relationship to the head of MEMBER IF RESPONDENT household? WAS DOESN'T KNOW, PRESENT USE YEAR OF AT LAST BIRTH TO HEAD.............1 SURVEY, SPOUSE...........2 ENTER Y1 CALCULATE AGE. SON/DAUGHTER.....3 HH ID CHECK THAT AGE STEP SON / NUMBER DAUGHTER.......4 IN QUESTION 4 AND FROM SISTER/BROTHER...5 YEAR OF BIRTH IN GRANDCHILD.......6 TRACKING QUESTION 3 ARE FATHER/MOTHER....7 FORM CONSISTENT. OTHER RELATIVE (SPECIFY)........8 ELSE, LIVE-IN SERVANT..9 ENTER 99 OTHER NONRELATIVES (SPECIFY).....10 NPS Y1 ROSTER YEARS
ID
7.
8.
9.
Did [NAME] eat meals in this household in the last 7 days?
For how many days in the last month was [NAME] present?
For the last 12 months has [NAME] stayed in this household for 3 months or more?
YES.. 1 NO...
CROSS OUT ID CODE IN THE FLAP AND DO NOT ADMINISTER OTHER SECTIONS FOR INDIVIDUALS WITH CODE 2
I N D I V I D U A L I D
YES...1 DAYS
NO....2
2 1
1
2
2
3
3
4
4
5
5
6
6
7
7
8
8
9
9
10
10
11
11
12
12
Q.9 EXCEPTIONS INFANTS LESS THAN 3 MONTHS NEW HOUSEHOLD MEMBERS BOARDING SCHOOL STUDENTS
B ROSTER - 4
10.
11.
For how many cumulative I months during N the last 12 D months has I [NAME] been V away from this I household? D U A L I D
MONTHS
12.
13.
What was [NAME]'s main Where is What was occupation for the past 12 [NAME]'s [NAME]'s age months? biological father? when [NAME]'s AGRICULTURE / LIVESTOCK.......1 father died? FISHING.............2 MINING..............3 TOURISM.............4 EMPLOYED: GOVERMENT...........5 PARASTATAL..........6 PRIVATE SECTOR......7 NGO/RELIGIOUS.......8 EMPLOYED(NOT AGRICULTURE): WITH EMPLOYEES......9 WITHOUT EMPLOYEES..10 UNPAID FAMILY WORK...............11 PAID FAMILY WORK...12 JOB SEEKERS........13 STUDENT............14 DISABLED...........15 NO JOB.............16 TOO YOUNG .........17
IF FATHER IS MEMBER OF HH, COPY ID. (►15) LIVING OUTSIDE OF HH......97 (►14)
AGE OF CHILD
15.
16.
17.
How many years of school did/does [NAME]'s father have?
Where is [NAME]'s biological mother?
What was [NAME]'s age when [NAME]'s mother died?
How many years of IS [NAME] AGED What is [NAME]'s school did/does 12 YEARS OR marital status? [NAME]'s mother ABOVE? have?
NO SCHOOL......1 SOME PRIMARY...2 COMPLETED PRIMARY......3 SOME SECONDARY....4 COMPLETED SECONDARY....5 MORE THAN SECONDARY....6 DON'T KNOW ....7
IF MOTHER IS MEMBER OF HH, COPY ID. (►18) LIVING OUTSIDE OF HH.....97 (►17)
AGE OF CHILD
18.
19.
NO SCHOOL......1 SOME PRIMARY...2 COMPLETED PRIMARY......3 SOME SECONDARY....4 COMPLETED SECONDARY....5 MORE THAN SECONDARY....6 DON'T KNOW..7
DEAD.......98
DEAD........98 DOES NOT KNOW.......99 (►14)
14.
YEARS
DOES NOT KNOW......99 (►17)
1 2 3 4 5 6 7 8 9 10 11 12
B ROSTER - 5
YES..1 NO...2 YEARS
(►NEXT)
MONOGAMOUS MARRIED...1 POLYGAMOUS MARRIED...2 LIVING TOGETHER....3 (►21) SEPARATED...4 (►25) DIVORCED....5 (►25) NEVER MARRIED...6 (►25) WIDOW(ER)...7 (►25)
20. What type of marriage ceremony did [NAME] have?
GOVERNMENT..1 RELIGIOUS...2 TRADITIONAL.3
Wife Number 1
2
3
4
21.
22.
Does spouse/ I partner live N in this D household I now? V I D U A L
23.
WRITE ID CODES OF Does [NAME] have SPOUSES WHO LIVE a spouse living IN THE HOUSEHOLD outside of this household?
24.
25.
How many spouses does [NAME] have who are residing outside of this household?
For how many From which district did you move? years have you lived in [WRITE THE COUNTRY IF OUTSIDE this TANZANIA] community? SEE CODES AT BACK OF QUESTIONNAIRE ENTER 99 IF LIVED HERE SINCE BIRTH
26.
IF 99 ► NEXT SECTION
I D YES.1
YES..1
NO..2 (►23)
2
3
4
(►25)
28.
Why did you move here?
In which district were you born? [WRITE THE COUNTRY IF OUTSIDE TANZANIA] SEE CODES AT BACK OF QUESTIONNAIRE
WORK RELATED.1 SCHOOL / STUDIES....2 MARRIAGE.....3 OTHER FAMILY REASONS....4 BETTER SERVICES / HOUSING..5 LAND / PLOT..6 OTHER, SPECIFY....7
ONLY MEN SHOULD BE ASKED
NO...2 1
27.
NUMBER
NUMBER OF YEARS
DISTRICT/COUNTRY NAME
CODES REGION DISTRICT
1 2 3 4 5 6 7 8 9 10 11 12
B ROSTER - 6
DISTRICT/COUNTRY NAME
REGION
CODES DISTRICT
SECTION C: EDUCATION 1. 2. IS [NAME] Can [NAME] read 5 YEARS and write? I OR N ABOVE? D I KISWAHILI...1 V ENGLISH.....2 I KISWAHILI & ENGLISH...3 D ANY OTHER U LANGUAGE..4 A NO..........5 L
3. Did [NAME] ever go to school?
RESPONDENTS: 5 YEARS AND ABOVE 4. At what age did [NAME] start school?
5. Is [NAME] currently in school?
6. Was [NAME] in school last year?
I D
YES..1
YES..1
YES..1
YES..1
NO...2
NO...2
(►9)
(►10)
NO...2
NO...2
(►NEXT)
(►29)
AGE
7. 8. What is the highest grade completed What by [NAME]? year did [NAME] PP.........1 ADULT......2 leave school PRIMARY SECONDARY D1........11 F1........21 for the D2........12 F2........22 last D3........13 F3........23 time? D4........14 F4........24 D5........15 'O'+COURSE.25 D6........16 F5........31 PUT D7........17 F6........32 "9999" D8........18 'A'+COURSE.33 IF OSC.......19 DIPLOMA...34 DON'T MS+COURSE.20 KNOW UNIVERSITY U1........41 U2........42 U3........43 U4........44 U5&+......45
►22
9. What grade is [NAME] currently attending?
10. What grade was [NAME] attending last year?
PP.........1 PRIMARY D1........11 D2........12 D3........13 D4........14 D5........15 D6........16 D7........17 D8........18 OSC.......19 MS+COURSE.20 UNIVERSITY U1........41 U3........43
PP.........1 PRIMARY D1........11 D2........12 D3........13 D4........14 D5........15 D6........16 D7........17 D8........18 OSC.......19 MS+COURSE.20 UNIVERSITY U1........41 U3........43
ADULT......2 SECONDARY F1........21 F2........22 F3........23 F4........24 'O'+COURSE.25 F5........31 F6........32 'A'+COURSE.33 DIPLOMA...34 U2........42 U4........44 U5&+......45
ADULT......2 SECONDARY F1........21 F2........22 F3........23 F4........24 'O'+COURSE.25 F5........31 F6........32 'A'+COURSE.33 DIPLOMA...34
U2........42 U4........44 U5&+......45
NOT YET STARTED ........90
11. CHECK Q5: IS [NAME] CURRENTLY ATTENDING LOCAL GOV' SCHOOL? CENTRAL LOCAL PEOP FOREIGN PE RELIGIOUS. CHARITABLE PRIVATE OR OTHER,
YES..1 NO...2 (►22)
1 2 3 4 5 6 7 8 9 10 11 12
C EDUCATION - 7
12. Who owns the school [NAME] attends? I N D I V I D U A L
LOCAL GOV'T......1 CENTRAL GOV'T....2 LOCAL PEOPLE.....3 FOREIGN PEOPLE...4 RELIGIOUS........5 CHARITABLE ORG ..6 PRIVATE ORG......7 OTHER, SPECIFY...8
13. Is this school a boarding school?
14. 15. How does [NAME] How long usually travel to school? does it take [NAME] to get to ON FOOT.........1 school by BY BIKE.........2 this means of transBY PRIVATE CAR/ VEHICLE.......3 portation? BY PUBLIC VEHICLE MINIBUS.......4 OTHER, SPECIFY..5
16. Does [NAME] get meals at the school (school feeding)?
17. Has [NAME] missed school in the last two schooling weeks?
FREE MEALS
I D
YES..1
YES..1
(►16) NO...2
MINUTES
YES..1
NO...2
NO...2
(►19)
18. Why was [NAME] absent from school?
PUBLIC HOLIDAY....1 SCHOOL CLOSED NOT IN BREAK...2 SCHOOL CLOSED IN BREAK...........3 ABSENCE TEACHER...4 ILLNESS CHILD.....5 ILLNESS HH MEMBER.6 FUNERAL...........7 DISCIPLINARY ACTION..........8 CANNOT MEET COSTS...........9 CHILD REFUSED....10 CHILD HAD TO WORK........11 OTHER, SPECIFY...12
1 2 3 4 5 6 7 8 9 10 11 12
C EDUCATION - 8
19. What is the status of the textbooks [NAME] uses for school?
NO TEXTBOOKS USED.1 ALL BORROWED FROM SCHOOL BUT CAN'T TAKE HOME.......2 ALL BORROWED FROM SCHOOL, SOME/ALL CAN TAKE HOME...3 SOME OWNED BY HOUSEHOLD........4 OTHER, SPECIFY....5
20.
21.
In the last week, approximately how many hours did [NAME] spend on homework or studying?
Has [NAME] had any problems at school?
IF NONE, WRITE '0'
HOURS
MINUTES
SELECT UP TO 2 NO PROBLEMS (SATISFIED)....1 INADEQUATE BOOKS/TOOLS....2 POOR TEACHING....3 INADEQUATE TEACHERS.......4 POOR ATTENDANCE OF TEACHERS....5 OVERCROWDED CLASSROOMS.....6 TOO EXPENSIVE....7 OTHER, SPECIFY...8 1
2
22. Did [NAME] I take the N Primary D School I Leaving V Exam I [PSLE]? D U A L
23. How did [NAME] score in the exam?
24. Did [NAME] take the Form 4 or Form 6 exam?
25. In what year did [NAME] take the exam?
26. Will you show me the exam certificate?
IF DON'T YES, YES, IT WAS KNOW, FORM 4..1 WRITE SHOWN.....1 YES, NOT SHOWN, 9999 FORM 6..2 HOUSEHOLD NO, DID HAS BUT NO TAKE.3 REFUSED...2 (►28) NOT FOUND...3
27. How did [NAME] score in the exam?
28. How much was spent on [NAME]'s education in the last 12 months by members of your household:
IF THERE WAS NO EXPENDITURE, WRITE '0'
KCM (MUKEJA)..1 KCK (MUKEJA)..2 OTHER, NOT MUKEJA, SPECIFY...3 NEVER ATTENDED..4 (►NEXT)
DIVISION 1..1 DIVISION 2..2 DIVISION 3..3 DIVISION 4..4 FAIL........5 DON'T KNOW..6
I D YES..1
PASS.......1
NO...2
FAIL.......2
(►24)
DON'T KNOW.3
29. Has [NAME] ever attended an adult education class? Which one?
School Books & Fees Material Uniform s s TSH TSH TSH
1 2 3 4 5 6 7 8 9 10 11 12
C EDUCATION - 9
Transport TSH
Extra
Other
tuition Contrib. TSH
TSH
Cost of TOTAL CASH & IN KIND Meals TSH TSH
30. How many months did [NAME] attend this adult education class?
NUMBER OF MONTHS
SECTION D: HEALTH
RESPONDENTS 12 AND OLDER SHOULD RESPOND FOR THEMSELVES 3. 4. 5. 6. 2. IS THIS Has [NAME] What type of health provider did [NAME] visit? How was the How much did [NAME] Did [NAME] have any PERSON visited a treatment financed? spend when you problems during the visit to I ANSWERING health care visited [PROVIDER]? the health provider? LIST UP TO TWO VISITS BY ORDER N FOR provider in UP TO TWO OF IMPORTANCE HIMSELF/ D the last 4 PROVIDERS NO PROBLEMS HERSELF? I weeks? (SATISFIED)......1 FREE V PRIVATE GOV. PARASTATAL POOR BUILDING / TREATMENT.....1 SPECIALISED HOSP...12 REFERRAL/SPEC. HOSP...1 I TOOLS............2 REGIONAL HOSPITAL ....2 HEALTH CENTER .....13 HEALTH LONG WAITING TIME.3 D INSURANCE...2 DISTRICT HOSPITAL ....3 DISPENSARY ........14 INADEQUARE TRAINED U OWN CASH......3 HEALTH CENTER ........4 STAFF............4 DISPENSARY ...........5 OTHER HAD TO WORK FOR A TOO EXPENSIVE.....5 PHARMACY ..........15 VILLAGE HEALTH POST PROVIDER....4 L LACK OF MEDICINE..6 (WORKER).............6 NGO................16 USE OF ASSET..5 CBD WORKER ...........7 OTHER, SPECIFY....7 TOOK LOAN.....6 OTHER, SPECIFY.....17 I GOT RELIGIOUS/VOLUNTARY D ASSISTANCE..7 REFERRAL/SPEC. HOSP...8 DIFFERED BY TSHS DISTRICT HOSPITAL ....9 HEALTH CENTER ......10 PROVIDER....8 DISPENSARY ..........11 YES..1 OTHER, SPECIFY.....9 YES..1 NO...2 1.
NO...2
(►7)
PROVIDER 1
PROVIDER 2
1
2
1
1 2 3 4 5 6 7 8 9 10 11 12
D HEALTH - 10
2
1
2
7.
8.
9.
How much in total did the household spend on [NAME] in the past 4 weeks for all illnesses and injuries, including for prescription medicine, tests, consultation, & inpatient fees, if any?
How much in total did the household spend on [NAME] in the past 4 weeks for medical care not related to an illness, including preventative health care, pre-natal visits, check-ups, etc., if any?
How much in total did the household spend on [NAME] in the past 4 weeks for non-prescription medicines, including Panadol, Fansidar, cough syrup, etc.?
INCLUDE VALUE REPORTED IN Q5
INCLUDE ESTIMATED VALUE OF ANY IN-KIND PAYMENTS. ALLOW UP TO TWO SERVICE PROVIDERS
TSHS
TSHS
TSHS
10.
I N D I V I D U A L
11.
During the How many stays and for last 12 how many nights was months, [NAME] hospitalized? were you hospital-ized or did [NAME] have an overnight stay(s) in a medical facility?
I D
12.
13.
14.
15.
16.
17.
What type of illness or injury did [NAME] have that led to his/her hospitalization?
What was the total cost of [NAME]'s hospitalization(s) or overnight stay(s) in a medical facility?
During the last 12 months, did [NAME] stay overnight(s) at a traditional healer's or faith healer's dwelling?
What was the total cost of [NAME]'s stay(s) at the traditional healer or faith healer?
IS THE RESPONDEN T A CHILD OF UNDER 5 YEARS OLD? (LESS THAN 60 MONTHS OLD)
Because of a physical, mental or emotional health condition…
FEVER.......1 MALARIA.....2 STOMACH.....3 DIARRHEA....4 HEADACHE....5 HEART.......6 LUNG........7 BROKEN BONE.8 MATERNITY...9 OTHER, SPECIFY..10
INCLUDE ESTIMATED VALUE OF ANY IN-KIND PAYMENTS.
YES..1 NO...2 (►14)
INCLUDE ESTIMATED VALUE OF ANY IN-KIND PAYMENTS.
YES..1 NEW STAYS
TOTAL NIGHTS FOR ALL STAYS
YES..1
NO...2 1
2
TSHS
(►16)
TSHS
(►31) NO...2
1 2 3 4 5 6 7 8 9 10 11 12
D HEALTH - 11
Does [NAME] have difficulty seeing, even if he/she is wearing glasses?
NO, NOT AT ALL.........1►! NO, NO DIFFICULTY WITH ASSISTIVE DEVICE......2 YES, SOME DIFFICULTY..3 YES, A LOT OF DIFFICULTY..4 CANNOT PERFORM.....5
18.
How old was [NAME] when the difficulty seeing began?
19.
Does [NAME] have difficulty hearing, even if he/she is wearing a hearing aid?
20.
How old was [NAME] when the difficulty hearing began?
USE CODES FROM Q17
AGE
AGE
21.
Does [NAME] have difficulty walking or climbing steps?
USE CODES FROM Q17
22.
How old was [NAME] when the difficulty walking or climbing stairs began?
AGE
23.
I N D I V I D U A L
Does [NAME] have difficulty remembering or concentrating?
24.
How old was [NAME] when the difficulty remembering or concentrating began?
I D USE CODES FROM Q17
AGE
25.
Does [NAME] have difficulty with self care (such as washing all over or dressing, feeding, toileting etc)?
USE CODES FROM Q17
26.
How old was [NAME] when the difficulty began?
AGE
27.
Using your usual [NAME OF LANGUAGE] language, does [NAME] have difficulty communicating; for example understanding or being understood?
USE CODES FROM Q17
28.
29. 30. CHECK QUESTIONS 17, 19, 21, 23, 25,27 IF [NAME] HAS ANY DIFFICULTY (ANSWERS 2, 3, 4, 5): How old Does this difficulty During the past 12 months, what was reduce the amount of measures were taken to improve [NAME] work [NAME] can do at [NAME]’s performance of when the home, at work or at activities? difficulty school? NONE..................1 communiSURGICAL OPERATION....2 cating MEDICATION............3 began? ASSISTIVE DEVICES YES, ALL THE (GLASSES, WHEELCHAIR, TIME..........1 BRACES, HEARING AID, YES, SOMETIMES..2 ARTIFICIAL LIMB)....4 NO..............3 SPECIAL EDUCATION.....5 NA (IF NOT SKILLS TRAINING WORKING OR (VOCATIONAL)........6 ATTENDING ACTIVITY OF DAILY LIVING SCHOOL).......4 (ADL) TRAINING......7 COUNSELING............8 At At At SPIRITUAL / TRADITIONAL.........9 Home School Work AGE OTHER (SPECIFY)......10
1 2 3 4 5 6 7 8 9 10 11 12
D HEALTH - 12
31.
32.
Did [NAME] sleep under a bednet yesterday?
How did the household How much did the obtain this bednet? household pay for the bednet?
YES UNTREATED NET..........1 YES TREATED NET < 6 MONTHS...2 YES TREATED NET > 6 MONTHS...3 NO.............4 (►34) DONT KNOW......5 (►34)
FREE GIFT.....1 (►34) PURCHASED.....2 PURCHASED W/ VOUCHER..3
33.
IF THE NET IS SHARED, ENTER THE AMOUNT FOR ONE MEMBER ONLY.
HAS REGISTERED... NEITHER ..... DON'T
TSHS
34.
35.
Does [NAME] possess their birth certificate?
In the last year, did [NAME] access a I medical exemption N at a public health D IF NO, PROBE: Has facility? I [NAME]'s birth ever V been registered with I the civil authority? D U A L HAS CERTIFICATE.1 I REGISTERED...2 NEITHER .....3 D DON'T KN0W...4
WOMEN 12-49 YEARS (Q 37-41) 37. 38. 39.
36. IS THE RESPONDENT A WOMAN AGED 12 TO 49 YEARS?
In the past 24 months, did [NAME] give birth to a child, even if born dead?
Did [NAME] regularly go to a health clinic when you were pregnant with your last child born in the last 24 months?
40.
Where did Who delivered [NAME] deliver this child? [NAME]'s last child born in the last 24 months?
HOSPITAL/ MATERNITY.1 CLINIC......2 AT HOME.....3 OTHER, SPECIFY...4
41. Was this birth registered?
DOCTOR OR CLINICAL OFFICER....1 NURSE.......2 MIDWIFE.....3 TRADITIONAL BIRTH ATTENDANT..4 FRIEND OR RELATIVE...5 SELF........6 OTHER, SPECIFY....7
YES.........1
YES..1
YES..1
NO..........2
NO...2
NO...2
YES..1
YES..1
DON'T KNOW..3
(►42)
(►NEXT)
NO...2
NO...2
1 2 3 4 5 6 7 8 9 10 11 12
D HEALTH - 13
CHILDREN
