Q1. Sex
Q2. What is your age?
Q3. What is your religion?
Q3OTHER SPECIFY
Q4. Are you the head of the household
Q5. What is your relationship with the head of the household
Q6. What is your occupation?
Q6OTHER SPECIFY
Q7. What is your highest educational level attained?
Q8. What is your average household monthly income?
Q9. How many people stay in this household on a regular basis?
Q10. How many children in this household are under 5 years of age?
Q10New. How many children in this household are under 5 years of age?
Q11. What is the main source of drinking water for members of your household?
Q11Other Other specify
Q12. What kind of toilet facilities does your household use?
Q12Other Other specify
Q13a Does your household have electricity?
Q13b Does your household have a radio?
Q13c Does your household have a television?
Q13d Does your household have a telephone?
Q13e Does your household have a refrigerator?
Q14. What type of fuel does your household use for cooking
Q15. Main material of the floor
Q16a. Does any member of your household own a bicycle?
Q16b. Does any member of your household own a motorcycle?
Q16c. Does any member of your household own a car or truck?
Q17. How many women in this household are known to be pregnant?
Q17New. How many women in this household are known to be pregnant?
Q18. How often do you read newspapers?
Q19. How often do you listen to radio?
Q20. How often do you watch television?
Q21s1 1. In your opinion, what causes malaria?
Q21other Other specify
Q22s1 1. What are the ways your household is currently using to avoid getting ma
Q22Other OTHER (SPECIFY)
Q23s1 Sleeping under mosquito net
Q23s2 Sleeping under insecticide treated net
Q23s3 Installing proofing in windows
Q23s4 Installing proofing in ventilators and open eaves
Q23s5 Removing/destroying mosquito breeding sites
Q23s6 Spraying house with insecticide
Q23s7 Clearing vegatation around homes
Q23s8 Closing windows and doors early in the evenings
Q23s9 Larviciding
Q23s10 Indoor residual spraying
Q23s11 Using body mosquito repellants
Q23s12 Using mosquito coils
Q24s1 Sleeping under mosquito net
Q24s2 Sleeping under insecticide treated net
Q24s3 Installing proofing in windows
Q24s4 Installing proofing in ventilators and open eaves
Q24s5 Removing/destroying mosquito breeding sites
Q24s6 Spraying house with insecticide
Q24s7 Clearing vegatation around homes
Q24s8 Closing windows and doors early in the evenings
Q24s9 Larviciding
Q24s10 Indoor residual spraying
Q24s11 Using body mosquito repellants
Q24s12 Using mosquito coils
Q25s1 1 Sleeping under mosquito net
Q25aother Other specify
Q25s2 1 Sleeping under insecticide treated net
Q25bother Other specify
Q25s3 1 Installing proofing in windows
Q25cother Other specify
Q25s4 1 Installing proofing in ventilators and open eaves
Q25dother Other specify
Q25s5 1 Removing/destroying mosquito breeding sites
Q25eother Other specify
Q25s6 1 Spraying house with insecticide
Q25fother Other specify
Q25s7 1 Clearing vegatation around homes
Q25gother Other specify
Q25s8 1 Closing windows and doors early in the evenings
Q25hother Other specify
Q25s9 1 Larviciding
Q25iother Other specify
Q25s10 1 Indoor residual spraying
Q25jother Other specify
Q25s11 1 Using body mosquito repellants
Q25kother Other specify
Q25s12 1 Using mosquito coils
Q25lother Other specify
Q26. If you were trained how to use the methods mentioned above in combined mann
Q27s1 1. Why would you not use all the methods?
Q27other Other specify
Q28s1 Sleeping under mosquito net
Q28s2 Sleeping under insecticide treated net
Q28s3 Installing proofing in windows
Q28s4 Installing proofing in ventilators and open eaves
Q28s5 Removing/destroying mosquito breeding sites
Q28s6 Spraying house with insecticide
Q28s7 Clearing vegatation around homes
Q28s8 Closing windows and doors early in the evenings
Q28s9 Larviciding
Q28s10 Indoor residual spraying
Q28s11 Using body mosquito repellants
Q28s12 Using mosquito coils
Q29s1 1 In which months of the year do you normally have many malaria cases in t
Q29Other others specify
Q30 When a child is sick with fever, how long after the fever begins should the
Q30Other others specify
Q31s1 1 What medicine may be given to a pregnant woman to help them avoid geting
Q31Other others specify
Q32 How many times does a woman need to take medicine (e.g. SP/Fansidar)
Q32New How many times does a woman need to take medicine (e.g. SP/Fansidar)
Q33 During the past 12 months, have you seen or heard any messages about malaria
Q34s1 1 Where did you hear or see messages?
Q34Other others specify
Q35s1 1 What is your preferred means of receiving health information?
Q35Other others specify
Q36. Has any child under 5 years in your household been ill with a fever at any
Q37. Did you seek advice or treatment for the illness from any source?
Q38. Why have you not sought advice or treatment from any source?
Q38other SPECIFY
Q39s1 1. Where did you seek advice or treatment?
Q39b Anywhere else?
Q39cIF UNABLE TO DETERMINE IF A H/F IS PUBLIC OR PRIVATE MEDICAL, WRITE THE NAME
Q39other Other specify
Q40. Where did you first seek advice or treatment?
Q41. How far (in kilometres)did you travel for this advice or treatment?
Q42. How many days after the fever began did you first seek advice or treatment
Q42New. How many days after the fever began did you first seek advice or treatme
Q43. How much did you pay for treatment?
Q44a What is the nearest health facility from your household and what is its dis
Q44Other others specify
Q44b Distance in kilometres?
Q45 if you were to go to this nearest facility, how would you most likely go the
Q45Other others specify
Q46 was this nearest health facility used the last time a member of this househo
Q47s1 1 Why was the nearest health facility not used the last time a member of t
Q47Other others specify
Q48 How many times do children under 5 years of age in this household normally s
Q49 Has any school going child in this household missed school in the past 6 mon
Q50 For how many days has this child or other children missed school in the past
Q51 When did you have your youngest child?
Q52 During your last pregnancy, did you take any drugs to keep from getting mala
Q53 Why didn't you take any drugs to keep you from getting malaria during your l
Q54 What drugs did you take?
Q54Other others specify
Q55 How many times did you take SP/Fansider during this pregnancy?
Q56 What was/were the possible reasons why you took or received SP/Fansidar only
Q56Other others specify
Q57 Did you get the (SP/Fansidar) during an antenatal care visit, during another
Q57Other others specify
Q58. At any time in the past 12 months, has anyone sprayed the interior walls of
Q59. How many months ago was the house sprayed?
Q60. Who sprayed the house?
Q60Other others specify
Q61. Did you pay for your dwelling to be sprayed?
Q62. How much did you pay for your dwelling to be sprayed?
Q63. Is there a community worker or community ...(CMD) who distributes malaria m
Q64. Does the community health worker currently have malaria medicines available
Q65. Do you normally open the windows on your house?
Q66. At what time are windows on your house normally closed?
Q67. Has your house ever been sprayed with insecticides (such as doom) to kill m
Q68. How often do you spray your house with insecticides to kill mosquitoes?
Q68Other others specify
Q69 When was the last time your house was sprayed with insecticides?
Q70 Is there any persistent stagnant water near your household for example resul
Q71 What is the estimated distance of that stagnant water from your household in
Q72. Does your household have any mosquito nets that can be used while sleeping?
Q73. How many mosquito nets does your household have?
Q74NET1. May I have a look at (all) the net(s) / their labels / packaging to est
Q74NET2. May I have a look at (all) the net(s) / their labels / packaging to est
Q74NET3. May I have a look at (all) the net(s) / their labels / packaging to est
Q75NET1. How many months ago did your household obtain the mosquito net?
Q75NET2. How many months ago did your household obtain the mosquito net?
Q75NET3. How many months ago did your household obtain the mosquito net?
Q76NET1. Where did you get the mosquito net from?
Q76NET2. Where did you get the mosquito net from?
Q76NET3. Where did you get the mosquito net from?
Q77NET1. OBSERVE (FROM NET, LABEL OF PACKAGING) OR ASK THE BRAND OR TYPE OF MOSQ
Q77NET2. OBSERVE (FROM NET, LABEL OF PACKAGING) OR ASK THE BRAND OR TYPE OF MOSQ
Q77NET3. OBSERVE (FROM NET, LABEL OF PACKAGING) OR ASK THE BRAND OR TYPE OF MOSQ
Q78NET1. Since you got the mosquito net, was it ever soaked or dipped in a liqui
Q78NET2. Since you got the mosquito net, was it ever soaked or dipped in a liqui
Q78NET3. Since you got the mosquito net, was it ever soaked or dipped in a liqui
Q79NET1. How many months ago was the net last soaked or dipped?
Q79NET2. How many months ago was the net last soaked or dipped?
Q79NET3. How many months ago was the net last soaked or dipped?
Q80NET1. Did anyone sleep under this mosquito net last night?
Q80NET2. Did anyone sleep under this mosquito net last night?
Q80NET3. Did anyone sleep under this mosquito net last night?
Q81NET1. What are the reasons why this net was not used?
Q81NET2. What are the reasons why this net was not used?
Q81NET3. What are the reasons why this net was not used?
Q82NET1 1. Can you provide the ages of the household members who slept under thi
Q82NET2 1. Can you provide the ages of the household members who slept under thi
Q82NET3 1. Can you provide the ages of the household members who slept under thi
Q82NET4 1. Can you provide the ages of the household members who slept under thi
Q82NET5 1. Can you provide the ages of the household members who slept under thi
Q83Net1. Among those who slept under this net, is anyone pregnant?
Q83Net2. Among those who slept under this net, is anyone pregnant?
Q83Net3. Among those who slept under this net, is anyone pregnant?
Weather Current Weather
Q1Observ All windows have complete shutters (e.g. glass or wooden)?
Q2Observ All windows fit well into frame/wall, no space for possible entry?
Q3Observ All windows have complete screening to prevent mosquito entry
Q4Observ Any window(s) found open?
Q5Observ Open windows have screening?
Q6Observ House has ventilators?
Q7Observ All ventilators have complete screening to prevent mosquito entry?
Q8Observ House has open eaves?
Q9Observ Open eaves have complete screening?
Q10Observ House has ceiling?
Q11Observ All external doors have complete shutters (such as glass or wooden)?
Q12Observ All external doors fit well into frame/wall, no space for possible mos
Q13Observ Any other oppening on house e.g. on the wall where mosquitoes may pass
Q14Observ Stagnant water present around house?
Q15Observ Vessels (such as tins and containers) that can potentially hold water
Q16Observ Overgrown vegetation within 5 metres of house present?
What is your average household monthly income?
What is your age?
How far (in kilometres) did you travel for this advice or treatment?
How much did you pay for treatment
Distance in Kilometer
When did you have your youngest child?
When was the last time our house wassprayed with insectcides?
What is the estimated distanceof that stagnant water form your household in metr
How many months ago did your household obtain the mosquito net?
How many people stay in this household on a regular basis
How many months ago was the house sprayed?
How much did you pay for your dwelling to be sprayed?