Prepared by

1. Melaku Lealem (BSc. ML)

2. Eshetu Gashaw (BSc. Mdf)
3. Melat Mulaw (BSc. Mdf)

Section 1: Socio-Demographic Information

1. Family Member List (presumably requesting a list of all family members)

2. Age…..

3. Sex/Gender

a. Male

b. Female

4. Religion

5. Education Level

a. Illiterate

b. Literate

c. Grades 1-8

d. Grades 9-12

e. More than Grade 12

6. Head of Household Status (This likely refers to whether the respondent is the
head of the household)

7. Employment Status (for those under 18 years old)

a. Agriculture

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 b. Business/Commerce

c. Government Employee

d. Homemaker

e. Not of Working Age (for those under 18)

f. Under 18 but Working

g. Student

8. Marital Status

a. Unmarried (over 18)

b. Married

c. Married but Separated

d. Divorced

e. Widowed

f. Not of Marriageable Age (under 18)

g. Married under 18

1.2 Household Income Status

1.2.1 What is the household's monthly income? (This would be a space for a
numerical answer)

1.2.2 What is the source of income? (This would be a space for a text-based
answer)

1.3 Communication Methods

1.3.1 Do you have a radio at home? a. Yes b. No

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1.3.2 Do you have a telephone at home? a. Yes b. No

1.3.3 Is there a public telephone in your area? a. Yes b. No

1.3.4 If you wanted to read a newspaper, could you obtain a recent one (meaning
within at least the last month)? a. Yes b. No

1.3.5 Is there a postal service available? a. Yes b. No

1.3.6 Is there internet service available? a. Yes b. No

Section 2: Environmental Health and Sanitation

2.1 Regarding Housing Structure:

a. Is the house built attached to neighboring houses or a fence?

b. Is the house built at some distance from neighboring houses or a fence?

2.2 Regarding the Dwelling:

a. How many rooms does the house have?

b. What is the area of each room in square meters?

c. How many people live in the house?

2.3 House Cleanliness:

a. Satisfactory (Floor made of tile or cement, easily cleaned; walls are smooth and
painted, ceiling has a cornice, and is free from dust, debris, and visible dirt.)

b. Moderate (Floor is earth, walls are mud and unplastered; ceiling has no cornice,
and is free from dust, debris, and visible dirt.)

c. Poor (Floor is earth; walls are mud and plastered, ceiling has no cornice, has
soot or cobwebs, and there is dust, debris, and other visible dirt.)

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2.4 Air Circulation:

a. Satisfactory (Two or more functional windows, window placement is not

parallel, and there is no foul odor.)

b. Moderate (One window only, and there is no foul odor.)

c. Poor (No windows or windows that don’t open, and there is a foul odor.)

2.5 Lighting Conditions:

a. Satisfactory (Windows in each room, light reaches everywhere, and the lighting
is sufficient to read a 12-letter sentence without difficulty.)

b. Moderate (Light enters through windows or another opening, but not evenly
distributed in all rooms.)

c. Poor (No windows or other openings, and it is dark.)

2.6 Do you have any domestic animals living in the house? a. Yes b. No

2.7 If yes (to question 2.6), where do they live? a. In a separate room b. In the same
room as people

2.8 What insects are present in the house or surrounding area?

a. Mosquitoes

b. Cockroaches

c. Fleas

d. Lice

e. Other (please specify)

2.9 How do you control insects in the house or surrounding area?

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a. By using nets or coverings

b. By using insecticide sprays

c. By maintaining personal and environmental hygiene

d. Other (please specify)

2.2 Regarding Cooking Fuel:

2.2.1 Do you have a separate kitchen from your living quarters? a. Yes b. No

2.2.2 If you have a kitchen, does it have a smoke vent/chimney? a. Yes b. No

2.2.3 What fuel source do you use for cooking? a. Wood and charcoal b. Electricity
c. Butane gas

2.2.4 If you use wood and charcoal, what type of stove do you use? a. Fuel-
efficient b. Non-fuel-efficient stove

2.2.5 If you use electricity, is the wiring exposed or improperly installed (not run
inside the walls)? a. Yes b. No

2.2.6 Are there any easily ignitable materials (e.g., gas or kerosene) stored in the
kitchen that could easily cause a fire? a. Yes b. No

2.3 Regarding Water:

2.3.1 Where do you get the water for your household?

a. Piped water

b. Protected well/spring

c. Unprotected well/spring

d. River

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2.3.2 If you get water from an unprotected well/spring or river, what do you do
before drinking it?

a. I boil it well, cool it, and place it in direct sunlight.

b. I place it in a container that allows sunlight to pass through.

c. I treat it with chlorine/water purifier.

d. Other (please specify)

2.3.3 How do you store drinking water in the house?

a. In clean jerrycans

b. In covered containers

c. In barrels

2.3.4 How do you draw drinking water from the storage container? a. Using a
tap/spout b. By dipping

2.3.5 If you draw water by dipping, do you have a dedicated clean dipper? (Ask to
see the dipper.)

a. Yes b. No

2.3.6 How long does it take to fetch water from the source and return (excluding
queuing time)? (Answer in minutes.)

2.3.7 What is your household's average daily water consumption in liters?

2.4 Regarding Food Preparation Hygiene and Safety:

2.4.1 What do you use to wash dishes? a. Water only b. Soap and water

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2.4.2 How do you dry the washed dishes? a. By hand only b. With a drying cloth c.
By placing them on a rack to air dry

2.4.3 Where do you store washed and dried dishes and food?

a. On the floor or on a shelf

b. On a wooden or mud shelf/rack

c. On a modern shelf/rack

2.4.4 Do you use separate containers for cooked and uncooked food? a. Yes b. No

2.4.5 Do you reuse leftover food? a. Yes b. No

2.4.6 If you reuse leftover food, do you handle it safely and correctly? a. Yes b. No

2.4.7 Do you prepare food while having diarrhea, a cough, a wound, or other
illness? a. Yes b. No

2.4.8 While preparing food, do you touch your skin, nose, or ears with your
fingers? a. Yes b. No

2.4.9 While preparing food, do you cover your hair, trim your nails, and remove
jewelry? a. Yes b. No

2.4.10 When do you wash your hands? (Multiple answers are possible.)

a. Before preparing food

b. After using the toilet

c. After cleaning children

d. After touching money or other potentially contaminated objects.

2.4.11 What do you wash your hands with? a. Soap and water b. Water only

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2.5 Regarding Toilets:

2.5.1 Do you have a toilet? a. Yes b. No

2.5.2 If you have a toilet, do you use it regularly? a. Yes b. No

2.5.3 Does the toilet have an attached handwashing facility? a. Yes b. No

2.5.4 What type of toilet is it?

a. Traditional pit latrine

b. Odorless toilet (with a vent pipe from the roof)

c. Flush toilet (water-sealed)

d. Other (please specify)

2.6 Regarding Solid Waste Disposal:

2.6.1 How do you dispose of solid waste?

a. In a pit dug in the compound

b. By scattering/littering

c. For garden compost

d. In a pit dug outside the compound

e. In an open field

f. Through the municipality/local government

2.6.2 Do you have a covered temporary storage area for solid waste? a. Yes b. No

2.6.3 How do you dispose of liquid waste?

a. In an open area within the compound

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 b. In a sand pit dug within the compound

c. In an open area outside the compound

d. Through a drainage system/sewer

2.6.4 What is the overall cleanliness of the compound? a. Clean b. Unclean

3.1 Regarding Maternal Health:

3.1.1 Number of women in the household in the reproductive age group (15-49
years)

3.1.2 Age at first marriage/cohabitation for married women.

3.1.3 Number of pregnant women currently in the household (if none, enter 0).

3.1.4 Number of pregnant women currently receiving antenatal care.

3.1.5 For pregnant women not receiving antenatal care, what is the reason for
each?

a. Unaware of its benefits

b. Do not want to

c. Don't know where to go

d. Lack of nearby health facility

e. Insufficient care from health professionals

f. Other (please specify)

3.1.6 What health problems do the currently pregnant women have?

3.1.7 Age at first childbirth for women who have given birth.
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3.1.8 Has any woman in the household experienced a miscarriage in the past year?
a. Yes b. No

3.1.9 If yes, how many times?

3.1.10 Number of women in the household who had a Cesarean section in the past
year.

3.1.11 Have they received postnatal care after delivery (for mothers with children
under 6 months)? a. Yes b. No

3.1.12 If no (to 3.1.11), what was the reason?

3.2 Regarding Family Planning (applies only to married or previously married

women in the household):

3.2.1 Do you want to have more children?

a. Yes, now

b. Yes, but after ----- years

c. No

3.2.2 Are you aware that there are methods to space births? a. Yes b. No

3.2.3 If yes, what types of family planning methods are you aware of?

3.2.4 Have you used family planning methods before? a. Yes b. No

3.2.5 Are you currently using family planning? a. Yes b. No

3.2.6 If yes, which family planning methods are you using?

a. Oral contraceptive pills

b. Emergency contraception

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 c. Injectable contraceptive (Depo-Provera)

d. Subdermal implant

e. Intrauterine device (IUD)

f. Condom

3.2.7 If not using family planning, why not?

a. Don't want to

b. Fear of health problems

c. Unavailability

d. Too expensive

e. Due to illness

f. Religious reasons

g. Partner/spouse does not approve/consent.

3.2.8 Do you intend to use family planning in the future? a. Yes b. No

3.3 Regarding Child and Maternal Immunization:

3.3.1 Have you had your children immunized? a. Yes b. No

3.3.2 If yes, which vaccines has your child received? (Multiple answers are
possible, verify with vaccination card)

a. BCG

b. Polio

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 c. Pentavalent vaccine

d. PCV (Pneumococcal conjugate vaccine)

e. Rotavirus vaccine

f. Measles vaccine

3.3.3 Number of women aged 15-49 years in the household who have received
tetanus toxoid immunization.

3.3.4 Of the immunized women, how many received the vaccine 1-5 times?

a. 1 time

b. 2 times

c. 3 times

d. 4 times

e. 5 times

3.4 Questions Concerning Childhood Illnesses:

3.4.1 Have any children under 5 years of age in the household been sick in the past
two weeks? a. Yes b. No

3.4.2 If yes, describe the illness for each child.

3.4.3 Among children under 5 years of age in your household:

a. How many have had their clitoris cut?

b. How many have had their labia cut?

c. How many have had their eyebrows shaved?

d. How many girls have been circumcised?

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3.4.4 Have any children in the household had diarrhea in the past 14 days? a. Yes
b. No

3.4.5 What treatment is given to a child with diarrhea?

Section 4: Various Community Health Information

4.1 Regarding Medication Use:

4.1.1 Where do you obtain medication when you are ill?

a. From a pharmacy

b. From a shop

c. From a traditional healer

4.1.2 Do you take prescribed medication at the specified time and dosage?

a. Yes b. No

4.1.3 What problems can arise from not taking medication at the prescribed time
and dosage?

a. Failure to cure the illness

b. The disease becomes resistant to the medication

c. Worsening of the disease

d. No problem

4.1.4 Have you ever used traditional medicine? a. Yes b. No

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4.1.5 If yes (to question 4.1.4), specify what type of traditional medicine you used.

4.2 Regarding Mental Health:

4.2.1 Have you heard of mental illness? a. Yes b. No

4.2.2 Do you know what causes mental illness? a. Yes b. No

4.2.3 Do you believe that mental illness is contagious? a. Yes b. No

4.2.4 Is there anyone in your family with a mental illness (including epilepsy)? a.
Yes b. No

4.2.5 Do you believe that mental illness is treatable? a. Yes b. No

4.2.6 If there is a mental illness in the family or community, where do you think
they should go for treatment?

a. A health facility

b. A place of worship/religious institution

c. A witch doctor/traditional healer

d. A traditional medicine practitioner

4.2.7 Does anyone in your household use addictive substances (such as alcohol,
khat, cigarettes, shisha)? a. Yes b. No

4.2.8 Do you believe that addictive substances like khat, cigarettes, shisha, alcohol,
etc., can cause mental illness? a. Yes b. No

4.3 Regarding Eye Diseases:

4.3.1 Do you know what trachoma (eye infection) is? a. Yes b. No

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4.3.2 If yes, what are the transmission routes of trachoma? (Multiple answers are
possible)

a. Poor environmental hygiene

b. Lack of personal hygiene

c. Contact with an infected person

d. Through flies

4.3.3 Do you believe that trachoma is preventable? a. Yes b. No

4.3.4 If yes, how can it be prevented? (Multiple answers are possible)

a. By maintaining personal and environmental hygiene

b. By seeking modern medical treatment

c. By using traditional medicine

d. By letting it go away on its own after some days

4.3.5 Is there anyone in the household suffering from trachoma? a. Yes, how
many? b. No

Section 5: Questions Addressing Maternal Health Status

5.1 Maternal Health Status (For mothers aged 15-49 years who have had more than
one child)

5.1.1 Do you experience any symptoms of anemia? (You can select more than one)

a. Blurred vision

b. Ear ringing

c. Dizziness

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 d. Easy fatigue

e. Heart palpitations during physical activity

5.1.2 Do you have any signs of anemia? (Symptoms that can be observed)

a. "Inner eye" paleness

b. Pale hands

c. No symptoms

5.1.3 Have you encountered any iron-rich foods during your pregnancy? (For
mothers who gave birth within the last 2 years or are currently pregnant)

a. Yes

b. No

5.1.4 If yes, when did you start consuming them?

5.1.5 How many times a day do you consume iron-rich foods? (For mothers who
gave birth within the last 2 years)

5.1.6 How many times a day do you consume iron-rich foods during the time you
are pregnant? (For mothers who gave birth within the last 2 years or are currently
pregnant)

5.1.7 Are there any foods that you avoid during pregnancy? (For mothers who gave
birth within the last 2 years or are currently pregnant)

a. Yes (please specify)

b. No

5.1.8 Are there any foods that you avoid while breastfeeding? (For mothers who
gave birth within the last 2 years or are currently breastfeeding)
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 a. Yes (please specify)

b. No

5.2 Child Feeding Practices (For children under two years)

5.2.1 When did you start breastfeeding your child?

a. Immediately after birth

b. After one hour

c. Did not breastfeed at all

5.2.2 Did you give your child anything before breastfeeding?

a. Yes

b. No

5.2.3 Did you give your child the first milk?

a. Yes

b. No

5.2.4 Have you exclusively breastfed your child?

a. Yes

b. No

5.2.5 For how long did you exclusively breastfeed? Without adding water: months

5.2.6 On average, how many times a day do you breastfeed your child?

5.2.7 When did you start giving your child additional food?

a. After months

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 b. Still breastfeeding only

5.2.8 What type of food did you first give your child?

a. Liquid food

b. Solid food

5.2.9 What type of additional food does your child receive?

a. Porridge

b. Other solid food

c. Other

5.2.10 Are you currently breastfeeding your child?

a. Yes

b. No

5.2.11 How long do you think about breastfeeding?

5.2.12 Does everyone in the household support breastfeeding?

a. Yes

b. No

5.3 Family Feeding Practices

5.3.1 What type of salt do you use at home?

a. Iodized salt

b. Non-iodized salt

c. Iodized salt is available

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5.3.2 When do you use salt?

a. When cooking

b. After cooking

5.3.3 Where do you store salt?

a. In an open container

b. In a closed container

6 Birth and Death Registration Related Questions

6.1 Within the past two years, were there any infants born in your household?

a. Yes

b. No

6.2 Within the past two years, were there any male infants born in your household?

6.3 Within the past two years, were there any female infants born in your
household?

6.4 Within the past two years, were there any male infants who died in your
household?

6.5 Within the past two years, were there any female infants who died in your
household?

6.6 Within the past two years, were there any deaths recorded in your household?

a. Yes

b. No

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6.7 Within the past two years, how many male deaths were recorded in your
household?

6.8 Within the past two years, how many female deaths were recorded in your
household?

6.9 What were the causes of death?

THANK YOU!!!

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