HOUSEHOLD QUESTIONNAIRE Questionnaire number: 1. To be

Sierra Leone Comprehensive Food Security and Vulnerability Analysis (CFSVA) 2010

HOUSEHOLD QUESTIONNAIRE Questionnaire number: |___|___| |___|___|___|

1/16

1. To be completed by Enumerator before the interview

2. To be completed by Supervisor and Coordinator

0.12 - Questionnaire Number:

|__|__| |__|__|__|

Team + Questionnaire

code numbering

0.13 – Date of supervisor checking

|__|__| / |__|__| / 2010

Day Month

0.14 – Supervisor name ______________________

Supervisor Code |__|__|

Remarks:

Signature of Supervisor:

_______________________________________

0.15 - Date of coordinator checking

|__|__| / |__|__| / 2010

Day Month

Coordinator name ____________________

0.16 - Coordinator Code |__|__|

Remarks:

Signature of Coordinator:

3. To be completed by data entry clerk

0.17 – First data entry

Date: |__|__| / |__|__| / 2010

Day Month

Name of data entry clerk ____________________

Remarks:

Signature of first data entry clerk(to be put after

the questionnaire is entered):

____________________________

0.18 – Second data entry

Date: |__|__| / |__|__| / 2010

Day Month

Name of data entry clerk ____________________

Remarks:

Signature of second data entry clerk(to be put after the questionnaire is entered):

____________________________

0.1 -

Enumerator name: __________________________________

Enumerator ID |__|__|

0.2 -

Date: |__|__| / |__|__| / 2010

Day Month

0.3 - Province name:

________________________

Province code:

|__|

0.4 - District name:

________________________

District code:

|__|__|

0.5 - Chiefdom name:

________________________

Chiefdom code:

|__|__|__|__|

0.6- Section name:

________________________

Section code:

|__|__|__|__|__|__|

0.7- Enumeration Area (EA) name:

_______________________

Enumeration Area (EA) code:

|__|__|__|__|__|__|__|__|

0.8-

Village/Town name:

_______________________

Village/Town code: |__|__|

0.9- Area: 1 = Rural 2 = Urban

0.10– Livelihood zone name:

_______________________

Livelihood zone code: |__|__|

0.11– Household head name:

___________________________

Household code |__|__|

Replacement of Household:

1 = Fulfilled 2 = Stopped 3 = Replacement of HH

Reason for replacement of Household: _______________________________

Please read the following consent form:

“My name is…. The Government of Sierra Leone and the World Food Programme are

collecting information here in ….(name of the place, village, area) on household food

security. Only few households are chosen randomly for the survey. I would like to

ask you some questions regarding your household. Please answer all the questions

truthfully. There is no judgment on your answers to the questions that will be asked.

The researchers will keep your responses confidential. There is no direct benefit to

you or your community in participating to this study. However, we hope that the

research will benefit Sierra Leone by helping us understand what people need in order to help the country move forward. Your participation is voluntary. You may

refuse to answer any question and you may choose to stop the discussion at any

time. Refusing to participate will not affect you or your family in any way. Do you

have any questions for us? You may ask questions about this study at any time. May

I begin the interview now?”

1. Yes 2. No

If no, why? ____________________

0.17 - Native language of

interviewee:

1. Arabic

2. Bullom 3. English

4. Fula

5. Kissi

6. Kono

7. Krim

8. Krio

9. Kuranko

10. Limba

11. Loko 12. Madingo

13. Mende

14. Sherbro

15. Susu

16. Temne

17. Vai

18. Yalunka

19. Other. Specify.

_________

0.18 - Language of the

interview:

1. Arabic

2. Bullom 3. English

4. Fula

5. Kissi

6. Kono

7. Krim

8. Krio

9. Kuranko

10. Limba

11. Loko 12. Madingo

13. Mende

14. Sherbro

15. Susu

16. Temne

17. Vai

18. Yalunka

19. Other. Specify.

_________

0.19 - Did an

interpreter

participate?

1 = Yes

2 = No



2/16

A household is defined as a person or a group of persons related or unrelated, living together or not, making common cooking arrangements and under the authority of the same household head For questions 1.3; 1.7; 1.8; 1.12; 1.13; 1.16; 1.19 and 1.21 use codes below

MEMBERS OF THE

HOUSEHOLD (HH)

RELATIO

N WITH THE

HOUSEH

OLD

HEAD

SEX AGE RELIGI

ON

ETHNIC GROUP/

NATIONA

LITY

MARITAL

STATUS

POLYGA

MY

ACTIVE

MEMBER

S

CHRONIC ILLNESS

ALL

HOUSEHOLD

MEMBERS

EDUCATION

ONLY

HH

MEMBE

RS

ABOVE 15

YEAR

OLD

ONLY CHILDREN FROM 6 TO 15 YEAR-OLD EDUCATION

All

children 6-15

All

children 6-15

who

ever

went

to school

If 1.14

and/or

1.15 is

NO

If 1.15

is yes

If

1.15

is

yes

If 1.18

is yes

If 1.14

is yes

or 1.15 is

no

If 1.20

is yes

ID List the persons

living in this

household, starting by the

household head

(including children

who are in school,

visitors present in

the HH since at least 6 months or

planning to stay

for at least 6 months)

Do not record full name, but only an

identifying first

name to refer to

the HH member

What is

(name)’s

relation to the

household

head?

Please

remember that the

household

head can

be a woman

1

Male

2 Femal

e

What was

(name)’s

age at his/her last

birthday?

If they do

not know

their exact birth date

ask for an

ID card, a voter ID

card or

use the event

calendar

If child less

than 1 year,

write 00.

What is

the

religion of the

househol

d head?

1 Muslim

2

Christian 3 Other

What is the

ethnic group

(for Sierra Leoneans)

or the

nationality (for non-

Sierra

Leoneans)

of the household

head?

What is the

marital

status of the head of

the

household?

How many

spouses

does the household

head

have?

To fill only if the

household

head is a

man, married or

cohabitatin

g

Is this HH

member

currently earning

an income

(in cash or in-

kind) for

the

household?

1 Yes 2 No

To fill for

all

household’s

members

Has any

member

been unable to function

fully/sick or

handicapped for at

least 3

months

over the past 12

months?

1 Chronic Illness

2 Mental

disability 3 Physical

disability

4 Not

disabled/chronically sick 1.13

If

(name)

has been unable

to

function fully,

sick or

disable

has s/he been

able to

work during

the past

12 months?

What is

the

highest level of

educatio

n attained

?

Has

(name)

ever been to

school?

1. Yes

2. No

If yes

1.17

Has

(name)

gone to school

during

the 2009-

2010

school

year?

1. Yes 2. No

If yes

1.17

What is

the main

reason for not

enrolling

(name) to

school?

If No at 1.15

Go to

1.20

Or

If No at 1.14

Go to

next person

Has

(name)

received a school

meal

during the

2009-

2010

school year in

the

school he/she

was

attending?

1. Yes

2. No

3. Only part of

the

school year

Did

(nam

e) miss

schoo

l for at

least

1

week in the

last

month of

schoo

l? 1.

Yes

2. No

If no

Go to

next perso

n

What

was

the main reason

for

missing

school?

If Yes at 1.15

Go to next

person

Has

(name)

abandoned

school

before completi

ng

primary

school/grade 6?

1. Yes

2. No

If no

Go to

next

person

What

was the

main reason

for

abandoning

school

before

completing

primary

school/grade 6?

1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21

01. |___| |___| |___|___| |___|

|__|__|

_________ |___| |___| |___| |___| |__| |___| |___| |___| |__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

02. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__| ______ |__|

|__|__| ______

03. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

04. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

05. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__| ______ |__| |__|

|__|__|

______ |__| |__|__|

______

06. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__| ______ |__| |__|

|__|__|

______ |__| |__|__|

______

SECTION 1 – SOCIO-DEMOGRAPHIC, CULTURAL AND EDUCATION CHARACTERISTICS OF THE HOUSEHOLD

1.3 - Relation with Household head

1 = Household (HH) head 2 = Spouse/partner

3 = Son/daughter 4 = Mother/father

5 = Brother/sister 6 = Other relatives by blood 7 = Other relatives by marriage 8 = Other non-relatives

1.7 – Ethnic group/Nationality

01 = Bullom 02 = Fula

03 = Kissi 04 = Kono

05 = Krim 06 = Krio 07 = Kuranko 08 = Limba

09 = Loko 10 = Madingo

11 = Mende 12 = Sherbro

13 = Susu 14 = Temne 15 = Vai 16 = Yalunka

17 = Non Sierra Leonans 18 = Other (specify below the box)

1.8 – Marital Status 1 = Single 2 = Married

3 = Cohabitating (living with partner, not married)

4 = Divorced or separated 5 = Widow or widower

1.12 – Chronic illness

1 = Yes, the same number of hours /days

2 = No, working for fewer hours/days

3 = She/He is completely unable to work 4 = Never worked

1.13 – Highest level of education attained by HH members

1 = No School 2 = Some Primary 3 = Completed Primary

4 = Some secondary 5 = Completed Secondary

6 = Vocational /Technical Institute 7 = Koranic 8 = College/University

1.16, 1.19 and 1.21 – Main reason for not enrolling to school, abandoning school before completing primary

school/grade 6 or missing school at least one week in the last month of school

01 = No functioning school in this village/ 02 = No money for school fee / costs

area they can attend/school too far 03 = Have to work in the family (gardening, fetching water, 04 = Have to work for an income taking care of siblings)

05 = Parents not interested in school 06 = Children not interested in school 07 = Sickness

08 = Initiation ceremonies 09 = Pregnancy 10 = Marriage 11 = School is located in insecure area

12 = No school feeding in the nearest school 13 = Other (specify below the box)



3/16

MEMBERS OF THE HOUSEHOLD (HH)

RELATIO

N WITH

THE HOUSEH

OLD

HEAD

SEX AGE RELIGI

ON

ETHNIC

GROUP/ NATIONA

LITY

MARITAL STATUS

POLYGAMY

ACTIVE

MEMBER

S

CHRONIC ILLNESS

ALL

HOUSEHOLD

MEMBERS

EDUCATION

ONLY HH

MEMBE

RS

ABOVE 15

YEAR

OLD

ONLY CHILDREN FROM 6 TO 15 YEAR-OLD EDUCATION

All

childre

n 6-15

All

childre

n 6-15 who

ever

went

to school

If 1.14 and/or

1.15 is

NO

If 1.15

is yes

If 1.15

is

yes

If 1.18

is yes

If 1.14

is yes

or

1.15 is no

If 1.20

is yes

ID List the persons

living in this

household, starting by the

household head

(including children who are in school,

visitors present in

the HH since at least 6 months or

planning to stay

for at least 6 months)

Do not record full

name, but only an identifying first

name to refer to

the HH member

What is

(name)’s

relation to the

household

head?

Please

remember

that the household

head can

be a woman

1

Male

2 Femal

e

What was

(name)’s

age at his/her last

birthday?

If they do

not know

their exact birth date

ask for an

ID card, a voter ID

card or

use the

event calendar

If child less than 1 year,

write 00.

What is

the

religion of the

househol

d head?

1 Muslim

2

Christian 3 Other

What is the

ethnic group

(for Sierra Leoneans)

or the

nationality

(for non-Sierra

Leoneans)

of the household

head?

What is the

marital

status of the head of

the

household?

How many

spouses

does the household

head

have?

To fill only

if the household

head is a

man, married or

cohabitatin

g

Is this HH

member

currently earning

an income

(in cash

or in-kind) for

the

household?

1 Yes 2 No

To fill for

all

household’s

members

Has any

member

been unable to function

fully/sick or

handicappe

d for at least 3

months

over the past 12

months?

1 Chronic Illness

2 Mental

disability

3 Physical disability

4 Not

disabled/chronically sick 1.13

If

(name)

has been unable

to

function

fully, sick or

disable

has s/he been

able to

work during

the past

12

months?

What is

the

highest level of

educatio

n

attained?

Has

(name)

ever been to

school?

1. Yes

2. No

If yes

1.17

Has

(name)

gone to school

during

the

2009-2010

school

year?

1. Yes 2. No

If yes

1.17

What is

the main

reason for not

enrolling

(name)

to school?

If No at 1.15

Go to

1.20

Or

If No at 1.14

Go to

next

person

Has

(name)

received a school

meal

during

the 2009-

2010

school year in

the

school he/she

was

attendin

g? 1. Yes

2. No

3. Only part of

the

school

year

Did

(nam

e) miss

schoo

l for

at least

1

week in the

last

month of

schoo

l?

1. Yes

2. No

If no

Go to

next

person

What

was

the main reason

for

miss

ing school?

If Yes at 1.15

Go to next

person

Has

(name)

abandoned

school

before

completing

primary

school/grade 6?

1. Yes

2. No

If no

Go to

next

person

What

was the

main reason

for

abandon

ing school

before

completing

primary

school/grade 6?

1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 1.10 1.11 1.12 1.13 1.14 1.15 1.16 1.17 1.18 1.19 1.20 1.21

07. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

08. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__| ______ |__| |__|

|__|__| ______ |__|

|__|__| ______

09. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

10. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

11. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__| ______ |__| |__|

|__|__| ______ |__|

|__|__| ______

12. |___| |___| |___|___| |___| |___| |__| |___| |___| |___|

|__|__|

______ |__| |__| |__|__|

______ |__| |__|__|

______

1.3 - Relation with Household head 1 = Household (HH) head 2 = Spouse/partner

3 = Son/daughter 4 = Mother/father

5 = Brother/sister 6 = Other relatives by blood

7 = Other relatives by marriage

8 = Other non-relatives

1.7 – Ethnic group/Nationality

01 = Bullom 02 = Fula

03 = Kissi 04 = Kono

05 = Krim 06 = Krio

07 = Kuranko 08 = Limba

09 = Loko 10 = Madingo

11 = Mende 12 = Sherbro

13 = Susu 14 = Temne 15 = Vai 16 = Yalunka

17 = Non Sierra Leonans

18 = Other (specify below the box)

1.8 – Marital Status

1 = Single 2 = Married

3 = Cohabitating (living with partner, not married)

4 = Divorced or separated 5 = Widow or widower

1.12 – Chronic illness

1 = Yes, the same number of hours /days

2 = No, working for fewer hours/days

3 = She/He is completely unable to work

4 = Never worked

1.13 – Highest level of education attained by HH members

1 = No School 2 = Some Primary 3 = Completed Primary

4 = Some secondary 5 = Completed Secondary

6 = Vocational /Technical Institute

7 = Koranic 8 = College/University

1.16, 1.19 and 1.21 – Main reason for not enrolling to school, abandoning school before completing

primary school/grade 6 or missing school at least one week in the last month of school 01 = No functioning school in this village/ 02 = No money for school fee / costs

area they can attend/school too far 03 = Have to work in the family (gardening, fetching water,

04 = Have to work for an income taking care of siblings)

05 = Parents not interested in school 06 = Children not interested in school 07 = Sickness

08 = Initiation ceremonies 09 = Pregnancy 10 = Marriage 11 = School is located in insecure area

12 = No school feeding in the nearest school 13 = Other (specify below the box)



4/16

2.1 Did any household member leave the community for at least 2 consecutive months in the past 12 months? Circle one

1 Yes

2 No go to question 2.3

2.2

If yes to question 2.1, please complete table on the right for each migrated member

ID Number to report from question 1.1

Main reason for leaving (use codes below)

|__|__| |__| ________________________________________

|__|__| |__| ________________________________________

|__|__| |__| ________________________________________

Codes for reason to leave: 1 = To do agricultural work 2 = To do non-agricultural work 3 = Divorce/Separation 4 = Education / studies 5 = To relieve strain on household 6 = Conflict 7 = Health treatment 8 = Family reunion/marriage 9 = Other (specify above)

2.3 Was the head of the household born in this village/town? Circle one

1 Yes go to Section 3

2 No

2.4 For how long has the head of the household lived in this village/town?

Years |___|___| Months |___|___|

2.5

Where did the household head move from?

Circle one

1 From another town outside the chiefdom

2 From the same chiefdom

3 From another chiefdom in the same district

4 From another district

5 From abroad/foreign country

2.6 Was the head of the Household living in a rural or urban area previously? Circle one

1 Rural

2 Urban

2.7 What was the main reason for moving? Circle one

1 Better access to agricultural land

2 Better access to roads

3 Better access to health centres and/or schools

4 Less exposure to natural hazards/disasters

5 Marriage

6 Better access to river or water sources

7 Better job opportunities

8 Better access to electricity

9 To join the family

10 Better access to market

11 To earn more money

12 Less exposure to insecurity go to question 2.8

13 Other. Specify: _____________________________

2.8

If the main reason for moving (in 2.7) is “Less exposure to insecurity”, what were the types of insecurity that the head of the household or other

members of the household were facing? Circle all that apply

1 Discrimination

2 Physical harm, danger, killing, wounding

3 Other form of violence

4 Theft or destruction of assets

5 Dispossession of land or land rights

6 Restrictions on movement, prevention of access to field, markets, jobs, social services

7 Other. Specify: _____________________________

2.9 Were you relocated or did you migrate? Circle one 1 Migrated go to Section 3

2 Relocated

2.10 If you relocated, did you receive any support in your relocation process? Circle one

1 Yes

2 No go to Section 3

2.11

What kind of support did you receive and who provided it? Circle all that apply

Type of support Support provider

1 Building material 1 Government

2 Money 2 International organizations

3 Land titles 3 Local NGOs

4 Agricultural inputs 4 Religious based organization

5 Skills training 5 Relatives/friends

6 Credit

6 Other (specify): ______________________

7 Household items (cooking pots, etc)

8 Food aid

9 Other (specify): ________________

SECTION 2 – MIGRATION AND RELOCATION



5/16

SECTION 3 – HOUSING AND FACILITIES

3.1

Do you or your household own or rent this house/dwelling?

Circle one

1 Own the house

2 Don’t own but live for free

3 Pay Rent

3.2

How many rooms, bed rooms + living room (kitchen and store are not included) does your household occupy?

|__|__| Rooms

3.3

What is the major material of the roof of your house? Observe and record. Ask the question if you have doubts

Circle one

1 Thatch (grass/straw)

2 Corrugated iron/zinc

3 Cement/concrete

4 Other, specify ____________________

3.4

What is the major material of the outside walls? Observe and record. Ask the question if you have doubts.

Circle one

1 Mud/mud bricks

2 Wood

3 Thatch (grass/straw) /bamboo

4 Corrugated iron/zinc

5 Stone/burnt bricks

6 Cement/concrete

7 Other, specify ____________________

3.5

What is the major material of the floor? Observe and record. Ask the question if you have doubts.

Circle one

1 Earth/mud

2 Wood

3 Stone/ bricks

4 Cement/concrete

5 Other. Specify: ____________________

3.6

What is the main source of lighting for this house?

Circle one

1 Pan lamp

2 Kerosene lantern

3 Candle

4 Electricity/NPA/BKPS

5 Generator

6 Firewood

7 Oil lamp

8 Torch light

9 Other. Specify: ____________________

3.7 What is your main source of energy for cooking?

Do not read answers. Circle one

1 Wood

2 Charcoal

3 Gas

4 Kerosene

5 Electricity/NPA

6 Other. Specify: ____________________

3.8

How long does it take to go and get (the source of energy for cooking) and come back? Write ZERO (000) if source is in the premise/dwelling or if vendor come to the house, and go to question 3.10.

|__|__|__| Minutes

3.9

How often does your household have to go and get the source of energy? Report the number of time and circle the frequency that apply

Number of time Frequency

|__| 1 Daily 3 Monthly

2 Weekly 4 Yearly

3.10 Have any members of your family experienced incidents or

problems while getting (the source of energy)? Circle one.

1 Yes

2 No

3.11

What type of toilet facilities does your household use?

Do not read answers. Circle one.

1 Flush latrine/toilet with water

2 Improved (VIP) pit latrine

3 Traditional pit latrine (no water)

4 (Partly) open pit (no roof or no wall)

5 Communal Latrine

6 None, bush, pond, river, stream

7 Bucket

8 Other. Specify :________________



6/16

SECTION 4 – PRODUCTIVE AND HOUSEHOLD ASSETS, INCOME FROM MIGRATION AND ACCESS TO CREDIT

4.1

Does your household own any of the following assets? Circle all that apply, but only the ones which are in working conditions (which could be used today)

Productive/transport assets

1 Shovel/spade 12 Hand tractor/power tiller

2 Sickle 13 Rice mill (fuel)

3 Hoe 14 Rice mill (Electricity)

4 Axe 15 Weaving tool

5 Plough 16 Fish net

6 Cutlass/ Machete 17 Boat/canoe

7 Pounding mill (wood), foot or hand

18 Sewing machine

8 Thresher 19 Bicycle

9 Cassava Grater/Gari processor 20 Push cart

10 Grainer 21 Motorcycle

11 Groundnut hauler 22 Car/truck

Household assets

23 Chair 33 Radio/radio-cassette

24 Table 34 Standing fan

25 Sleeping mats 35 TV

26 Bed 36 Refrigerator

27 Lantern 37 Generator (run by fuel)

28 Torchlight 38 Mobile phone

29 Umbrella 39 DVD player

30 Mosquito net 40 Air-conditioning

31 Watch/clock 41 Computer/laptop

32 Stove (gas/fuel)

4.2 Has your household received any money or support in kind from relatives living outside your household in the past 12 months?

1 Yes


3.12

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

Do not read answers. Circle one.

1 Piped water (into dwelling, yard or plot)

2 Public tap

3 Tubewell/Borehole with pump

4 Protected dug well

5 Protected spring

6 Rain water

7 Unprotected well

8 River, stream or pond

9 Other, specify _________________

3.13

Usually, how long does it take to go to the main source of water, get water and come back?

Write ZERO (000) if water is on premise. |__|__|__| Minutes

3.14 Have any members of your family experienced incidents or problems while going to get water? Circle one.

1 Yes

2 No

3.15 Are there intermittent cuts in the water source? Circle one. 1 Yes


3.16

If yes, how long was the last cut? |__|__|__| days

3.17

If there are entire months in which the main water source is not available, please indicate which months.

Circle each month where water is not available

1 January 7 July

2 February 8 August

3 March 9 September

4 April 10 October

5 May 11 November

6 June 12 December



7/16

4.3 How often did your household receive such support in the past year? Circle one.

1 12 times a year or more (at least every month)

2 Between 6 and 11 times a year (min. every 2 months)

3 Between 3 to 5 times a year

4 Less than 3 times a year (occasionally)

4.4

Do you expect to continue to receive such support in the coming year? Circle one.

1 Yes

2 No

3 Do not know

4.5 How much money (in cash or kind) did your household receive in the past 12 months?

|__|__|__|__|__|__|__|__|__| Leones

4.6

Did the household borrow money in the last 12 months? Circle one.

1 Yes

2 No go to Section 5

4.7 What is the total amount of money the household has borrowed in the past 12 months?

|__|__|__|__|__|__|__|__|__| Leones

4.8

Who did you borrow money from?

Circle all the options which apply

1 Relatives / friends

2 Charities / NGOs

3 Local lender

4 Bank

5 Co-operatives / Osusu

6 Village head

7 Company/middle men

8 Farmer organization

9 Other. Specify: ___________________

4.9

How much of the loan do you expect to be able to repay during the next 12 months? Circle one.

1 No repayment possible

2 Less than ½ possible

3 More than ½ possible

4 Full repayment possible

5 Already repaid

4.10

What was the main use of the largest loan taken in the last 12 months?

Circle only the main one

1. To buy agricultural inputs 2. Food purchases

3. Labour 4. Funerals

5. Business investment 6. Wedding

7. Land purchase 8. Medical expenses

9. House purchase or construction, Home improvement

10. Education

11. Traditional ceremonies (initiation, festivals, societies, etc)

12. Other. Specify: _______________________

4.11

In the last 3 months, how often did you use credit or borrow money to purchase food?

Circle one

1 Never

2 On one occasion

3 On two occasions

4 On three occasions

5 On more than three occasions

Section 5 – AGRICULTURE AND LIVESTOCK

5.1

Does your household have access to agricultural land? Circle one

1 Yes


5.2

How much area have your household cultivated during the last agricultural season (February 2009 to February 2010)?

|__|__|__|.|__| Acres

5.3

If the household was living here before the civil war and was already cultivating land, which proportion of your land is currently cultivated compared to before the civil war? Circle one

1 More than before (> 100%)

2 Whole/most of the land (> 90%)

3 More than half of the land (50% - 90%)

4 Less than half of the land (10% - 50%)

5 A very little part of the land (<10%)



8/16

5.4

What are the terms of the land tenure of the head of the household? Circle all the options which apply

1. Permission from Chief (communal)

2. Long-term lease (more than one cropping season)

3. Short term rental (one cropping season or less)

4. Inheritance

5. Family/clan owned 6. Outright ownership/purchase

7. Other. Specify: __________________________________

5.5 Does any woman in your HH own her own plot of land?

Circle one

1 Yes


5.6 If the husband has several wives, does each of the wives have her own plot of land?

Circle one

1 Yes

2 No

5.7 Do youth (18 to 35 year-old) in your household do separate farming?

Circle one

1 Yes


5.8

If youth do separate farming in your household, how do they access land? Circle all that apply

1. Permission from Chief (communal)

2. Long-term lease (more than one cropping season)

3. Short term rental (one cropping season or less)

4. Inheritance

5. Family/clan owned 6. Outright ownership/purchase

7. Other. Specify: ____________________________________

5.9 How many members of your HH participated in farm work during the last agricultural season (February 2009 to February 2010)?

Male |__|__| (above 18 year-old)

Female |__|__| (above 18 year-old)

Children |__|__| (under 18 year-old)

5.10 During the last agricultural season (February 2009 to February 2010), did you pay people (cash or in-kind) to help you with agricultural activities? Circle one

1 Yes

2 No

5.11 At any time during the last agricultural season (February 2009 to February 2010), did you have difficulty finding enough people to hire for your agricultural activities?

Circle one

1 Yes

2 No

3 Not applicable

5.12 During the last agricultural season (February 2009 to February 2010), did you keep any of your land uncultivated?

Circle one

1 Yes


5.13

If you kept any of your land uncultivated, what were the 3 main reasons in order of importance? Put maximum 3 |__| |__| |__| First Second Third

1 To replenish soil fertility/fallow 5 Lack or not enough inputs (seeds, fertilizer, pesticides, etc)

2 Lack or not enough labour in the community

6 Lack of marketing opportunity for agricultural products

3 Access to more land than required for annual farming

7

87

Other. Specify:

_________________________ 4

Lack or not enough tools and equipment

5.14 What were the 3 main reasons which prevented you from obtaining a higher production during the last agricultural season (February 2009 to February 2010)? List maximum 3 in order of importance. Do not mention response options

1. |__||__| 2. |__||__| 3.|__||__|

___________ __________ _________

Codes for reasons:

01 = Lack of seeds 02 = Lack of tools 03 = Lack of fertilizer/pesticide 04 = Lack of household labour 05 = Lack of training/technical advice

06 = Low soil fertility

07 = Pests and diseases

08 = Heavy rains

09 = No marketing opportunities

10 = Lack of cash/money

11 = Lack of land

12 = Late/insufficient rain

13 = Household is engaged in other activity

14 = Theft of crops

15 = Lack of access to credit

16 = Ill health/ sickness

17 = Don’t need/want to

18 = Lack of storage facilities 19 = Other (specify below the box)



9/16

5.15

Which of the functioning services

and/or installations listed exist in your area and you have used during the last agricultural season (February

2009 to February 2010)?

Circle all that apply

5.15 a. Does this (service/installation) exist in your village/town?

If no go to next service/installation

5.15 b. If yes in 5.15.b,

have you used this (service/installation) during the last agricultural season (February 2009 to February

2010)?

Drying floor 1= yes 2 = No 1 = Yes 2 = No

Store (Cereals/ grains) 1= yes 2 = No 1 = Yes 2 = No

Rice mill 1= yes 2 = No 1 = Yes 2 = No

Cassava grater 1= yes 2 = No 1 = Yes 2 = No

Thresher 1= yes 2 = No 1 = Yes 2 = No

Power tiller/hand tractor 1= yes 2 = No 1 = Yes 2 = No

5.16 Do you use irrigation for your cultivated land in the dry season? 1= yes 2 = No

5.17 During the last agricultural season (February 2009 to February 2010) how was the timing of rain compared to a normal year? Circle one

1 Early

2 Late

3 Normal

5.18 During the last agricultural season (February 2009 to February 2010) how was the amount of the rains compared to a normal year? Circle one

1 Too much

2 Too little

3 Normal

5.19

What inputs did you use during the last agricultural season (February 2009 to February 2010)? What was the main source? Was it free (gift), paid, on loan or coming from the household own production? Circle all the types of inputs that apply- Enter the main source code

5.19 a. Type of inputs 5.19 b. Main source 5.19 c. Was it free, paid, on loan or produced by the household? Circle one per row

1 Chemical Fertilizers |__| 1=Free 2=Paid 3=Loan 4=Own production

2 Natural/organic fertilizers/compost |__| 1=Free 2=Paid 3=Loan 4=Own production

3 Pesticides/herbicides |__| 1=Free 2=Paid 3=Loan 4=Own production

4 Improved seed varieties |__| 1=Free 2=Paid 3=Loan 4=Own production

5 None

Codes for main source: 1. Government 2. NGO 3. Market/shops/traders

4. Relatives/friends/family members 5. Local creditors coming to the farm 6. Agrobusiness Centers (ABC)/Farmer Based Organization (FBO)/Cooperatives 7. Other

5.20 What do you use to work your

land?


1 Hand tools

2 Animal traction

3 Hand tractor/Power tiller

4 Big tractor

5.21

Where did you store your harvest of the last agricultural season (February 2009 to February 2010)?


1 Indoors – In basket / bags

2 Indoors – Open storage

3 In outside storage hut in boxes

4 Communal storage

5 Lockable house/Mini-store

6 Stack storage

7 Seed bank

8 Other (specify) ________________________

5.22 Do you or any member of your household belong to an agricultural

related organization? Circle one

1 Yes


5.23

Which type of organization?


1 Farmer Based Organization (FBO)

2 Cooperatives societies

3 Farmer field school

4 Traders associations

5 Others. Specify: _________________________



10/16

5.24 What were the various crops/products cultivated by your household during the last agricultural season (February 2009 to February 2010)? Circle all that apply

Crop codes 01. Up- land Rice 02. Low-land/swamp Rice 03. Maize/Corn 04. Sorghum 05. Millet/ Fundi 06. Beans 07. Cotton 08. Plantain 09. Sugar cane 10. Okra 11. Groundnuts 12. Coffee

13. Cassava 14. Leafy vegetables (cassava leaves,

potato leaves, crain crain) 15. Kola nuts 16. Banana 17. Pineapple 18. Fignut 19. Other fruits (ex : citrus, mango,

etc) 20. Sweet potatoes 21. Vegetables (e.g. Tomato, cabbage,

onions) 22. Water yam

23. Chinese yam 24. Tobacco 25. Oil Palm 26. Cocoyam 27. Cocoa 28. Irish potatoes 29. Cashew nuts 30. Ginger 31. Other 1. Specify: ___________________ 32. Other 2. Specify: ___________________

5.25 Commodity

5.26 a. During the past 12 months, did your household cultivate (commodity)? 1 = Yes 2 = No if No go

to next line

5.26 b. During the last 12 months, how many months did your household largely depend on market purchases to consume (commodity)?

5.26 c. During the last 12 months for how many months did your household largely depend on your own production to consume (commodity)?

5.26 d. During the last 12 months for how many months did your household largely depend on gifts to consume (commodity)?

5.26 e. During the last 12 months for how many months did your household not consume (commodity)?

5.26 f. In the last 12 months, did your household sell some or all of your harvest of (commodity)? 1 = Yes 2 = No If No

got to next line

5.26 g. If yes, were these sales part of your usual income-generating activities to meet HH needs? 1 =Yes 2 = No if yes

5.28 2 = No

5.26 h. If no, what were the main reasons for unusual sales? List max. 2 reasons in order of importance 01 = Ran out of money/stocks to buy other food and/or other basic commodities 02 = Had to re-pay debts 03 = Contribute to ceremonies/festivals 04= Migration of family member/travel 05 = Cover medical expenses 06 = Pay for school -fees 07 = Good harvest (selling unexpected surplus) 08 = Other (specify below the box)

Please note: 1b+1c+1d+1e = 12 months

1 Rice |__| |__||__| months

|__||__| months

|__||__| months

|__||__| months |__| |__|

1. |__||__| 2.|__||__| ______ ______

2 Cassava |__| |__||__| months

|__||__| months

|__||__| months

|__||__| months |__| |__|

1. |__||__| 2.|__||__| ______ ______

5.27 If you have cultivated rice during the last agricultural season (February 2009 to February 2010), what was the main source of seeds?

Circle one

1 Purchase

2 Own stock

3 Government

4 NGOs/INGOs/CBOs

5 Borrow/exchange

6 Shared from neighbors/relatives (free)

7 Other. Specify: _____________________

5.28 Did you have a vegetable/backyard garden during the last agricultural season (February 2009 to February 2010)? Circle one

1 Yes

2 No

5.29 Did you grow vegetables in the uplands during the last agricultural season (February 2009 to February 2010)? Circle one

1 Yes

2 No

5.30 Does your household own any farm-animals? 1 Yes 2 No 5.32

5.31

If you own farm-animals, how many of each of the following animals do you own? (Circle all the owned animals AND report the number. If a specific animal is not owned, write ZERO)

1 Sheep/Goats |__||__||__|

2 Pigs |__||__||__|

3 Cattle |__||__||__|

4 Chickens/Ducks/Gooses/Turkey/Guinea fowl |__||__||__|

5 Rabbits |__||__||__|

6 Other. Specify. __________________________ |__||__||__|

5.32 Does the household practice fishing/fish farming? 1 Yes 2 No Section 6



11/16

5.33 What type of fishing/ fish farming does your household practice? Circle all that apply

1 = Ocean 2 = River 3 = Creek/stream 4 = Natural freshwater pond/lake

5 = Artificial fishpond 6 = Swamps 7 = Lagoon (salt water) 8 = Other. Specify: ____________

SECTION 6 – LIVELIHOODS

A – What are the 3 main activities (report maximum 3) that sustained your household during the past YEAR (12 months), using the activity codes below. Do not prompt.

B – Estimate the cash value (in Leones) of the yearly output from each activity

C - Using proportional piling method, estimate contribution to total income of each activity. (total100%)

D – Report who participates in each activity, using the participants codes below.

Activities

A. What are your household’s main activities throughout the last 12 months? Rank maximum 3 income activities Use livelihood activity codes

B. Estimated cash value of yearly output from this activity. Include estimates of outputs directly consumed by the household

C. Using proportional piling method, estimate the relative contribution to total income of each activity (%)

D. Who is involved in terms of gender? 1. Male(s) 2. Female(s) 3. Both

E. Who is involved in terms of age? 1. Children (below 18) 2. Adults (over 18) 3. Both

6.1

Main |__|__|___________ |__|__|__|__|__|__|__|__|__| Le |__|__|__| % |__| |__|

6.2 Second |__|__|___________ |__|__|__|__|__|__|__|__|__| Le |__|__| % |__| |__|

6.3

Third |__|__|___________ |__|__|__|__|__|__|__|__|__| Le |__|__| % |__| |__|

TOTAL 100 %

6.A. Income activity codes 1 = Production and sale of food crops

2 = Production and sale of cash crops

3 = Livestock rearing and/or selling

4 = Salt extraction

5 = Fishing

6 = Mining of minerals (gold, diamond, iron, bauxite)

7 = Unskilled wage labour – agriculture

8 = Unskilled wage labour – non-agriculture

9 = Skilled wage labour (including taxi, poda poda, okada driver/bike riding)

10 = Handicrafts /Artisan (tailoring, weaving, carving, pottery, painter, etc)

11 = Palm oil extraction

12 = Wood cutting/coal burning

13 = Petty trading

14 = Trading, Seller, Commercial activity

15 = Remittances/ Migrating labour

16 = Salaries, Wages (employees, longer-term)

17 = Mining of sand and stone

18 = Aid (Government, local NGO, international NGO)

19 = Gift (family, friends)

20 = Hunting and selling bush meat (i.e. cutting grass)

21 = Gathering and selling of wild food (bushyams, plums, blactombla, etc)

22 = Extraction of palm wine (poyo)

23 = Palm wine selling

24 = Production and sale of vegetables and/or fruits

25 = Begging

26 = Cart puller/push cart

27 = Others (specify next to the box)



12/16

SECTION 7 – EXPENDITURES

In the last 30 days, how much money have you spent on each of the following items or service for the household?

Estimated Expenditure during the last month, both cash and

credit (Le)

7.1 - Rice |__||__||__||__||__||__||__||__||__|Le

7.2 - Cassava (including cassava products, gari, foofoo, tho) |__||__||__||__||__||__||__||__||__|Le

7.3 - Bread |__||__||__||__||__||__||__||__||__|Le

7.4 - Sweet potatoes/tubers (yams) |__||__||__||__||__||__||__||__||__|Le

7.5 - Bulgur |__||__||__||__||__||__||__||__||__|Le

7.6 - Corn and CSB |__||__||__||__||__||__||__||__||__|Le

7.7 - Pumpkin, plantain, banana |__||__||__||__||__||__||__||__||__|Le

7.8 - Beans, peas, lentils |__||__||__||__||__||__||__||__||__|Le

7.9 - Fresh vegetables (including green leaves) and fresh fruits |__||__||__||__||__||__||__||__||__|Le

7.10 - Nuts, groundnuts, benniseeds |__||__||__||__||__||__||__||__||__|Le

7.11 - Eggs |__||__||__||__||__||__||__||__||__|Le

7.12 - Milk/diary products |__||__||__||__||__||__||__||__||__|Le

7.13 - Fish |__||__||__||__||__||__||__||__||__|Le

7.14 - Meat (beef, pork, mutton, chicken/poultry, goat) |__||__||__||__||__||__||__||__||__|Le

7.15 - Palm oil/ Oil / Butter |__||__||__||__||__||__||__||__||__|Le

7.16 - Sugar / Salt / Maggi / Manpo |__||__||__||__||__||__||__||__||__|Le

7.17 - Tea/coffee |__||__||__||__||__||__||__||__||__|Le

7.18 - Other food expenditures |__||__||__||__||__||__||__||__||__|Le

7.19 - Beverages (soda, mineral water) |__||__||__||__||__||__||__||__||__|Le

7.20 - Alcohol (including palm wine, poyo) and tobacco |__||__||__||__||__||__||__||__||__|Le

7.21 - Soap /soap powder / detergents |__||__||__||__||__||__||__||__||__|Le

7.22 Transport (fuel, taxi, okada, bus) |__||__||__||__||__||__||__||__||__|Le

7.23 Firewood/char-coal |__||__||__||__||__||__||__||__||__|Le

7.24 Kerosene |__||__||__||__||__||__||__||__||__|Le

7.25 Phone credit/ phone charge |__||__||__||__||__||__||__||__||__|Le

7.26 Internet browsing |__||__||__||__||__||__||__||__||__|Le

7.27 Religious/charity donations |__||__||__||__||__||__||__||__||__|Le

7.28 Recreation (cinema, gambling, etc) |__||__||__||__||__||__||__||__||__|Le

7.29 Hair cut/hairdressing/barber |__||__||__||__||__||__||__||__||__|Le

Since Christmas (last 6 months), how much money have you spent to acquire each of the following items or service?

Estimated Expenditure during the last month, both cash and

credit (Le)

7.30 Agricultural/farming equipment, tools, seeds |__||__||__||__||__||__||__||__||__|Le

7.31 Veterinary expenses for farm animals |__||__||__||__||__||__||__||__||__|Le

7.32 Fishing tools |__||__||__||__||__||__||__||__||__|Le

7.33 Cash for hiring labour (group and individual) |__||__||__||__||__||__||__||__||__|Le

7.34 Food for hiring labour (group and individual) |__||__||__||__||__||__||__||__||__|Le

7.35 Medical expenses, health care |__||__||__||__||__||__||__||__||__|Le

7.36 Education: fees, uniform, material |__||__||__||__||__||__||__||__||__|Le

7.37 Other clothing, shoes |__||__||__||__||__||__||__||__||__|Le

7.35 Celebrations, social events, funerals, weddings, ceremonies |__||__||__||__||__||__||__||__||__|Le

7.36 Utilities (electricity, gas, water, fuel) |__||__||__||__||__||__||__||__||__|Le

7.37 Payment of interest rates |__||__||__||__||__||__||__||__||__|Le

7.38 Housing (repairs, construction, maintenance) |__||__||__||__||__||__||__||__||__|Le

7.39 Housing rent |__||__||__||__||__||__||__||__||__|Le

7.40 Other long term expenditures:_____________________ |__||__||__||__||__||__||__||__||__|Le



13/16

SECTION 8 – FOOD SOURCES AND CONSUMPTION

Food Item

8.1

Number of days

eaten during the last 7 days

(From 0 to 7)

8.2

Main Food Source over the

last 7 days

Use food source codes

QU. 8.2: Food Source codes

01 = Own production (crops, animals)

02 = hunting, fishing

03 = gathering

04 = borrowed

05 = purchase

06 = exchange labor for food

07 = exchange items for food

08 = gift (food) from family/ relatives

09 = food aid (NGOs etc.)

10 = begging

11 = bought on credit

12 = other

0 = Not

consumed

1 = One day

2 = Two days

3 = Three days

4 = Four days

5 = Five days

6 = Six days

7 = Seven days

1. Rice |__| |__|__|

2. Cassava products (foufou, gari, tho)

|__| |__|__|

3. Tubers products (potato, yam)

|__| |__|__|

4. Maize/corn |__| |__|__|

5. Bulgur |__| |__|__|

6. Millet/fundi |__| |__|__|

7. Other cereals |__| |__|__|

8. CSB (Corn Soya Beans) mix

|__| |__|__|

9. Bread |__| |__|__|

10. Fish |__| |__|__|

11. Fish as condiments |__| |__|__|

12. Meat (Chicken, etc) |__| |__|__|

13. Meat as condiments |__| |__|__|

14. Eggs |__| |__|__|

15. Milk/dairy products |__| |__|__|

16. Beans/ peas/lentils |__| |__|__|

17. Vegetables |__| |__|__|

18. Green leaves (cassava, potato, crincrin, okra…)

|__| |__|__|

19. Fresh fruits |__| |__|__|

20. Nuts (groundnuts, benniseeds)

|__| |__|__|

21. Oil / Palm oil/ Butter |__| |__|__|

22. Sugar |__| |__|__|

23. Condiments (Salt, Maggi, pepper, etc)

|__| |__|__|

24. Nuts as condiments |__| |__|__|

25. Tea/coffee/cocoa |__| |__|__|

26. Bushyams and other wild fruits and wild vegetables

|__| |__|__|

8.3 How many meals did the household eat yesterday?

Adults |__|

Children (from 1 to 5 years old)

|__|

8.4 During the past 12 months, during which months your household had difficulties getting enough food to eat? Circle all that apply

June 2009

July 2009

August 2009

Sept. 2009

Oct. 2009

Nov. 2009 Dec. 2009

Jan. 2010

Feb. 2010

March 2010

April 2010

May 2010



14/16

Section 9 SHOCKS AND COPING STRATEGIES

Has your household experienced any shocks/difficulties in the last 12 months?

1 yes 2 no 9.4

If yes, please rank the shocks and report the three most serious.

9.1 Rank 3 main shocks by order of importance

9.2 Did (shock) decrease your household’s ability to produce or purchase food? 1 = Yes 2 = No 3 = Don’t know

9.3 What did the household do to compensate for this loss of income and/or assets? Report the three most important coping strategies. Choose from the strategy codes below

1= main 2 = second 3= third

1st |__|__|

_______________

2nd |__|__|

_______________

3rd |__|__|

_______________

a Drought/irregular rains |__| |__|

b Floods |__| |__|

c Crops damaged by insects, disease, animals |__| |__|

d Lack of HH labour |__| |__|

e Lack of agric. inputs (seeds, fertilizer, etc) |__| |__|

f HH member temporarily ill or injured |__| |__|

g HH member chronically ill |__| |__|

h Unusually high level of human disease |__| |__|

i Lack or loss of employment |__| |__|

j High costs of agric. inputs (seed, fertilizer, etc.) |__| |__|

k Political problems |__| |__|

l Price fluctuations |__| |__|

m Insecurity |__| |__|

n Death of a working household member |__| |__|

o Death of other household member |__| |__|

p Theft of Money/valuables |__| |__|

q Theft of crops or livestock |__| |__|

r Severely high level of livestock diseases |__| |__|

s Prison/detainment |__| |__|

t Fire |__| |__|

u Other, specify_____________________ |__| |__|

Coping strategies codes:

01 Rely on less preferred, less expensive food 02 Borrowed food, helped by relatives 03 Purchased food on credit 04 Consumed seed stock held for next season 05 Reduced the proportions of the meals 06 Reduced number of meals per day 07 Skipped days without eating 08 Some HH members migrated 09 Sold durable household goods 10 Sent children to live with relatives 11 Reduced expenditures on health & education

12 Spent savings 13 Gathering (wild food product) 14 Sold or consumed livestock 15 Sold agricultural tools, seeds or other inputs 16 Worked for food only 17 Sold crop before harvest 18 Rented out land 19 Sold land 20 Borrowed money 21 Other (specify below the box)

9.4 In the past 7 days, how many days your household had to:

Frequency (0-7)

0= 0 day 1= 1 day 2= 2 days 3= 3 days

4 = 4 days 5 = 5 days 6 = 6 days 7 = 7 days

a - Rely on less preferred and less expensive foods? |__|

b - Borrow food, or rely on help from a friend or relative? |__|

c - Limit portion size at mealtimes? |__|

d - Restrict consumption by adults in order for small children to eat? |__|

e - Reduce number of meals eaten in a day? |__|



15/16

SECTION 10 – CHILD HEALTH AND NUTRITION

ASK TO THE SELECTED RESPONDENT ONLY IF THERE ARE CHILDREN 0 - 59 MONTHS (under 5 years) IN THE HOUSEHOLD, otherwise terminate the interview Enter the children’s first names and ask the following question for one child at a time

10.1 10.2

10.3

10.4

10.5 10.6 10.7 10.8 10.

9

10.

10

10.11 10.

12

10.13 10.

14 10.15 10.16

Identification Relation

Pregnancy

Mother MUAC

Date of birth of the child

Age of the child

Size of child

Sex Sickness Antenatal care

Hygiene practice

First name

Use codes from

qu. 1.1 on

section 1

Mother’s/Car

e taker’s ID

no.

Use code from qu.

1.1

88=missing/

absent at

the

interview

What is

your

relation

to

(child)?

Are

you

1 the

mother

2 the

care

taker

3 someb

ody

else

Are

you

pregna

nt?

1 yes

2 no

Mother Mid

upper Arm

Circumferenc

e

(in

millimeters)

888 =

mother or care taker

absent

999 = MUAC

exceeded

34.2

If available Date of Birth

from the Medical Card or

other certificate where

date of birth is reported

(Use format

dd/mm/yy)

Child’s age

in months

If no certificate,

report age

of child in

months

using the

event calendar

for

children

When

the child

was

born

was he/she?

1 Very

large

2

Normal 3 Very

small

4 Do

not

know

Wha

t is

the

sex

of the

child

?

1=Male

2=F

emal

e

Has

the

child

been

sick in the

last 2

week

s?

1=

yes

2=

no

10.14

What was

the child’s

main

sickness?

1= Fever

2=

Repeated

coughs/

breathing

difficulties 3=

Diarrhea

(3 or

more

stool per

day for 3 days or

one large

watery

stool or

blood in

stool) 4=

Measles

5=Other

Was

the

child

take

n to a

heal

th

servi

ce?

1

yes

2

no 10.

13

If child

was not

taken,

why?

1= Illness not

serious

2= Far

away/lack

transport

3= Lack money

4= Does

not like/

distrust

doctor/he

alth profession

al/nurse

5= Other

source of

treatment

was used 6= Other

(specify

below the

box)

If

the

child

had

diarrhea

as

main

sick

ness

in the

last

2

wee

ks,

did you

give

him/

her

Oral

Rehydra

tion

Solu

tion

(OR

S)? 1=

yes

2=

no

If you

are the

mother,

at the

time you were

pregnant

, who did

you see

more

often for antenatal

care/advi

ces?

1 Doctor

2 Nurse

3 Midwife 4

Relative/f

riend

5 TBA

6

Traditional

herbalist

7

Communi

ty Health

officer 8 No one

When do you, the

mother/care taker, wash your

hands?

1= yes 2= no

Child

ID

Child

name

After

usin

g

the toile

t

Befor

e

eatin

g or feedi

ng an

infant

After

doin

g a

dirty job

like

chan

ging

an

infant's

diap

er

Befo

re

hand

ling food

s or

after

hand

ling

raw food

s e.g

mea

t

|__|__| _____ |__|__| |__| |__| |__||__||__|

mm |__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|

|__|__| _____ |__|__| |__| |__|

|__||__||__|

mm |__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|

|__|__| _____ |__|__| |__| |__|

|__||__||__|

mm |__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|

|__|__| _____ |__|__| |__| |__|

|__||__||__|

mm |__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|

|__|__| _____ |__|__| |__| |__|

|__||__||__| mm

|__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|

|__|__| _____ |__|__| |__| |__|

|__||__||__|

mm |__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|

|__|__| _____ |__|__| |__| |__|

|__||__||__|

mm |__|__|/|__|__|/|__|__| |__|__| |__| |__| |__| |__| |__|

|__|

_____ |__| |__| |__| |__| |__| |__|



16/16

10.1 10.2

10.17 10.18 10.19

10.20 10.

21

10.22

Identification Child MUAC Breastfeeding Products received by the child since this time yesterday

First name

Use codes from qu. 1.1

on section 1

Report same codes as

previous page

Mother’s/C

are taker’s

ID no.

Use code

from qu.

1.1

88=missing/absent at

the

interview

Child Mid

upper Arm

Circumference

MUAC

(in

centimeters)

Only for children from

6 to 59

months

Was the

child ever

breastfed

?

1= yes

2= no

3 = do

not know

Did the

child

receive

breast milk

yesterday

?

1= yes

2= no

Since this time yesterday, did he/she receive any of the following:

1 yes 2 no

Read each item aloud and record response before proceeding to the next

item

Yest

erda

y,

has the

child

recei

ved

1 solid

2

semi

-

solid

3

soft

food

Did the child eat food from any of the following food groups

yesterday?

1 yes 2 no

Read each item aloud and record response before

proceeding to the next item

a.

vitam

in,

min

era

l supple

ments

?

b.

medic

ine ?

c.

pla

in w

ate

r?

d.

sw

eete

ned,

flavoure

d w

ate

r,

fruit juic

e,

tea o

r in

fusio

n?

e.

ora

l re

hydra

tion s

olu

tion (

ORS)?

f. infa

nt

form

ula

?

g.

tinned,

pow

dere

d o

r fr

esh m

ilk?

h.

any o

ther

liquid

s?

i. s

olid o

r sem

i-solid (

mushy)

food?

a.

Gra

ins,

roots

and t

ubers

b.

Vegeta

ble

s a

nd n

uts

c.

Dairy p

roducts

(m

ilk,

yogurt

,

cheese)

d.

Fle

sh foods (

meat,

fis

h,

poultry

and liv

er/

org

an m

eats

)

e.

Eggs

f. V

itam

in-A

ric

h f

ruits a

nd

vegeta

ble

s

g.

Oth

er

fruits a

nd v

eg.

h.

CSB p

rem

ix

Child ID Child name

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

|__|__| __________ |__|__| |__|__|.|__|

cm |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |__| |_| |_| |_| |_| |_| |_| |_| |_|

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HOUSEHOLD QUESTIONNAIRE Questionnaire number: 1. To be