(A) Interviewee demographic data |
Name |
|
Address |
|
Birth date and age |
|
Gender |
|
Race/color |
|
Birth place |
|
Residence time in the current address |
(B) Dwellers demographic data |
Name |
|
Age |
|
Gender |
|
Relationship with the interviewee |
|
Residence time > 12 months in the address |
|
Schooling |
|
School’s name and location |
(C) Malaria episodes reported by the interviewee |
If remembers the 1st malaria |
|
Self-reported malaria in the last 12 months |
|
Inactivity and days lost due to malaria |
|
If needed health care in the last 12 months |
|
Places sought for health care |
|
Hospitalization due to malaria |
(D) Interviewee’s last episode of malaria |
How he/she discovered he/she had malaria |
|
Date of the last malaria episode (self-report) |
|
If he/she had malaria symptoms |
|
Type of malaria (falc, vivax) |
|
Access and adherence to treatment |
(E) Malaria information for each dweller |
If they had malaria in the last 12 months (as reported by the interviewee) |
|
Hospitalization to treat malaria |
(F) Household goods |
Ownership of goods and animals |
(G) Occupation and income of the household |
Types of occupation of the householders |
|
Number of dwellers contributing for the household income |
|
If the income received is considered sufficient |
(H) Characteristics of household |
Material used for the wall, roof, ceiling and floor |
|
Presence of crevices in the walls |
|
Number of rooms |
(I) Household access |
Type of access to the household (river, road, trail) |
|
If household is accessible by vehicle on a rainy day |
|
If access is paved |
|
If you would like the street, road or trail to be paved |
|
If the access to the house floods |
|
If flooding reaches the door of the house |
|
Presence of natural or artificial water bodies in the vicinity of the house and the neighborhood |
(J) Water supply |
Type of access to water |
|
Source of water used in the kitchen and for drinking |
|
How water is stored |
|
If water is treated before consumption |
|
Frequency at which water is missing at home |
|
Place where the households shower |
|
Place where the households wash dishes and clothes |
|
Place where the households go to tend to their physiological needs |
(L) Garbage disposal |
How waste is disposed |
|
Frequency of garbage collection by public service, if available |
(M) Access to electricity |
If there is electricity in the household |
|
If available: its source, installation date, if time-restricted or fails, cost |
|
If not available: source of energy used |
(N) Mobility and potential exposure to malaria |
Routine activities from 6 p.m. to 9 p.m. |
|
Frequency and motivation to go close to water bodies and the forest |
|
Frequency of sleeping in the wild |
|
Frequency, motivation, and length of stay in farms |
|
If needs to travel to receive social benefits, frequency and length of stay |
|
If needs to travel for working, frequency and length of stay |
|
If traveled for any other reason in the last 12 months, frequency and length of stay |
(O) Use of bednet and other protections |
Ownership of impregnated and standard bednets and quantity |
|
General usage, usage in the last night |
|
Problems with bednet usage |
|
If the households use other methods for mosquito protection |
|
Recommendations or suggestions for improving the health of the family and community |