2.

1 Identification Partticulars

S# Full name of the House Relationship to Sex Age Ethnicity Religion Education for For People 18Year & Above
hold member(le usual the head of People-7
members) houshold years of age
&above

1 Marital Occupational
status status

10

Relation Religion Educational levels Marital status Occupation Status

[Link] read&Write [Link] [Link]
[Link] [Link] 2. cant read&Write [Link] [Link] employee
[Link] [Link] For formal education attendants, [Link] [Link]
[Link]/ daughter [Link] [Link] grade completed [Link] [Link]
[Link] relative [Link] 5. Student
[Link]-relatives [Link] [Link]
[Link]
For married men indicate the number of wives that the individual has in bracket ,example- [Link] tebder
1(2) means amarried man who has two wives [Link]/Over age
10. Other(specify)
2.2 MEANS OF COMMUNICATION [Link]

[Link] you have radio set? [Link] [Link]

[Link] you have private T.V set? 1. yes [Link]
3. .Do you have telepone in your house? 1. yes [Link]
[Link] no, Do you have access to public telephone? 1. yes [Link]
[Link] you want to read ,do you get news papers fairly in time(within a month after
their disscunination)? [Link] [Link]
6. Do you have access to postal service? 1. yes [Link]
Woreda-------------K/Ketema/Keble------Village/Zone----------House Number-------------

1
2.3. FEMILY INCOME

[Link] of generating income [Link] 2. Selting fuel wood & charooat 3. Daily labor [Link]
(specify)____________

[Link] is the haverage annual income of the family?_____________( in money or in kind and if reported on a monthly
basis convert it into annual)

[Link] you have additional source? [Link] [Link]

[Link] yes, specify the source and amount___________________

2.4 VITAL STATISTICS

[Link] there any birth in the 12 months in the family? [Link] [Link]

2. If yes complete the following from for each birth

S# Name of the mother Age if the Status of Sex of the Place of Attendant of deilver
mother birth new born delivery
1
2
3
[Link] birth [Link] [Link]
[Link] birth [Link] institiution [Link]
[Link] person
[Link] there any death in the last 12 months in the family? [Link] [Link]

[Link],yes complett the following from for each birth

No Sex Age at death Perceived cause of death

1
2
3
1. Was there any one sick among the members of the family during the last two weeks? [Link] [Link]

2. if,yes complete the following for each sick family momber

S# Sex Age Ailmonts Days lost from usual Did the person If yes where?
[Link] [Link] activty due to illnoess seekany help?
[Link] [Link] [Link]
[Link] [Link]
[Link]
1
2
3
[Link] institution
[Link] bealer

2 [Link]
[Link] of the house [Link] [Link] [Link](specify)________________
[Link] of 2.1Roof [Link] [Link] 3. Other(specify)_______________
2.2 Wall [Link] [Link] and/or coment [Link] 4. Wood [Link]
[Link] [Link] 2. Wood [Link] 4. Other(specify)_______________
[Link] of people living in the same house_______________________
4. Number of rooms for human use______________________
[Link] of kitchen avaliable for the household
1.1 Sepatate room but attached to the main house
1.2 Sepatate room and detched from the main house
1.3 No kitchen room
6. Number of rooms for stor___________________________
[Link] domestio animals live with humans in the house [Link] [Link]
[Link]
1.1 presence of windows [Link] [Link]
1.2 Dual door [Link] [Link]
1.3 Remarks on ventilation [Link] [Link] [Link]
[Link] Illumination -(natural light) 1. Good [Link] [Link]
[Link] of the room 1. Good [Link] [Link]
[Link] requirement of the house
11.1 In good condition need no maintenace
11.2 In fair condition need no maintenace now
11.3In poor condition needs urgent maintenace
[Link] of space for
[Link]-yard garden [Link] [Link]
12.2. play –ground for children [Link] [Link]
[Link] of water supply
[Link] water [Link] the house or compound [Link] tap
[Link] stand point
[Link] [Link] [Link] protected spring
[Link] 1. Protected 2. Un protected spring
[Link] or river [Link] 2. Un Zoned
[Link] (specify)____________
[Link] there water point for maintenace? 1. Yes 2. NO
[Link] yes, what is that water source for maintenace? _____________ ___________________
[Link] of water source fom the house ___________________ ____________________
[Link] in meters or kilometers ____________________ _______________________
4.2 Estimated in minuters or hours ___________________________________
N.B(Estimation should inclde in and from distance or time___________________

3
[Link] of water consumed by family for aii purposes
 5.1 Total daily consumption of water in jaga,tins or other locally accepted unit
5.2 Capacity of continer in litters__________________
[Link] daily consumption of water by family for all purposes
6.1. In jags, tns or other locally accepted unit_______________
[Link] of the container in litters __________________
6.3. Capacity of the container in capits ___________________
[Link] type of container do you use to store the water? _________________
[Link] how long do you store it? _____________________
[Link] you have acover for a container? 1. Yes [Link]
[Link] do you use to draw water from the container _________________
4.3.1. Excreta disposal
[Link] there latrine facility for the family? 1. Yes [Link]
[Link] yes, what is the type of latrine available?
[Link] latrine 2. Ventilated improved pit 3. Water curriage type
[Link] is the status of excrets disposal ownership?
[Link] by the family 2. Shared or communal [Link](specfy)____________
[Link] distance of latrine from
1. The hous (estimated in meters)______________
2. water source (estimated in meters)___________(For pit latrines only)
5. what is the status of latrine
[Link] [Link] needs repair [Link] in dirty [Link]
[Link] status of the latrine
[Link] by the family in good condition 3. Families don’t lik to use it
[Link] is not functional 4. Other(specfy)____________
[Link] latrine is not functional what are the resasons
1. Filled
[Link] is unsightly dirty [Link] do not like to use it
[Link] needs repair & dangerous 5. Other(specfy)___________
[Link] the answer is not for Q1 where do you members of the house hold go for latrine__________
[Link] there is no latrine,is there adequate spase for constuction? 1. Yes [Link]
[Link] latrine constuction affordsble for the family? 1. Yes [Link]
4.3.2 REFUSE DISPOSAL
[Link] do you dispose refuse?
[Link] [Link] field [Link] service 4. Other(specfy)___________
[Link] you have problems of insects and other vecmin? 1. Yes [Link]
3If yes type of vermin
[Link] fly [Link] [Link] [Link] bugs [Link] [Link] 7. Other (specfy)___________
4. where do you usually slaughter animals for food?
[Link] abatoir [Link] field [Link] places (specfy)___________

4
Maternal and child health(for 15-49 years old women who delivered at least
once)
[Link] Information
[Link] of the woman (in years)_______________
[Link] of woman
[Link] [Link] [Link] [Link] 5. Others (specfy)___________
[Link] of womans 1. Single [Link] [Link] [Link]
[Link] women__________________________
[Link] of husband (If currenty maried)
[Link] status of women__________________
[Link] [Link]& write oniy 3. 1-6 Grade 4. 7-12 Grade [Link] grade 12
7. Literacy status of husband (If currenty maried)
[Link] Read& write, 2. Read& write 3. 1-6 4. 7-12 5. Above grade 12
[Link] status ofwomen ____________________
9. Ocupational status ofwomen husbabd (If currenty maried) _______________
II. Family plannig
[Link] you know about contraceptive? 1. Yes [Link]
2. If yes to question [Link] of the following method(s) do you know?
[Link] [Link]- provers 3. Rhythm 4. Loop [Link] _________
[Link] [Link] 8. Others (specfy)___________
3. If yes to question 1. do you use of the method(s) mentioned in question 2? 1. Yes [Link]
4. . If yes to question 3, Specify the type of method(s) in question 2 that you use
_____________
5. If yes to question 3, what is the reason that you use contraceptive?
[Link] problem 2. For spacing [Link] reason 4. Others (specfy)___________
[Link] no to question 3, what are your main reasons for not using contraceptives?
[Link] of sid effects [Link] [Link] not know sources
[Link] of husbands consent [Link] available 6. Others
(specfy)__________________
7. If no to question 3, what do you do when you want to space your next pregnancy?
______________
lII. Family plannig coverage
(To be fillied for all 15-49 years of age women in the releted household)
[Link] you know any mathed for controllm spacing births? 1. Yes [Link]

5
2. If yes,which ones do you know?
 [Link] [Link]-provers [Link] [Link] 5. Condom
[Link] [Link] 8. Others (specfy)___________
[Link] you ever used any of the above methods? 1. Yes [Link]
4. If yes,which ones?______________________
[Link] you use them currently? 1. Yes [Link]
6. If yes,which ones?
1. pill 2. Depo-provers 3, Rhythm [Link] 5. Condom
[Link] [Link] 8. Others (specfy)___________
[Link], why?
[Link] of side effects 4. Cost
[Link] disapproval 5. Others (specfy)___________
[Link]

[Link] does your husband (Partner) feel about birth control methods?
1.I don’t know 2. He has no felling
[Link] feels positive about them 4. He is indifferent about them
IV. Pregnancy and Delivery
[Link] at first marriage if ever maried_________________
2. Age at first pregnancy if ever pregnant_______________
3. Total number of if ever
1.pregnancies________2. Live births______3.Abortion______4. Still births________
[Link] did youdeliver your last child? [Link] [Link] station/clinic [Link] center
[Link] institution 5. Others (specfy)___________
[Link] deliverd at home, who attended the delivery?
[Link] [Link](untrained) 3. Neighbors [Link] personnel
5. Relatives 6. Others (specfy)___________
[Link] you have any health problem(s) during?
[Link] 1. Yes [Link]
[Link] 1. Yes [Link]
[Link] 1. Yes [Link]
[Link] you go to the near by health facility during pregancy 1. Yes [Link]
[Link] yes who? [Link] sick [Link] regular checkup
[Link] yes, mention the problem(s) ________________________________________
[Link] you take any during premancy in the following areas?

6
A.6 Diarrheal Morbiditty Treatment Survey Formal for Under-five Children
 [Link]
Woreda__________k.ketema/kebele__________Zone village____________
House Number_________ Name of the head of the household___________
Relationship of the person interviewed to the child
1. Mother [Link] 3. Grand mother [Link] [Link] [Link] relative
7. Care taker 8. Noo-relative 9. Other
Name of the child_______________________________________
II. Information for under-five children
[Link] of the child in monthr_________________
[Link] of the child. [Link] 2. Female
3. Hasthe childhad diarrhoea in the past two weeks?
(Ask if any child had 3or more loose watery or bloody stools in 24 hour period)
1. Yes [Link] (if no, go to question 11)
[Link] yes to question 3, what type of diarrhoes was it? [Link] [Link] [Link]
[Link] was the number of the diarrhoea attacks( episodes) during the last two weeks?_______
6. On average for how long has the child had diarhoea in each episode?______(in days)
[Link] treatment child received?
[Link] remedies(e.g soup,tea,rice water, fruit-juice)
2. Homemads solution (salt& suger)
[Link] rehydration salt(ORS)
[Link] therpy (TV)
[Link] treatment given
6. Other (specify) __________________________
[Link] of treatment
[Link] health post [Link] 3. Health station 4. Health center 5. Other/speecify
[Link] ORS was used whereis the source of supply?
[Link] Health post 2. Health instititutions(HS,H.C, HOSP.)
[Link] vendor [Link]-operative shop [Link] shop 6. Other/speecify_____________
[Link] you continue treatment with ORS? 1. Yes [Link]
[Link] you knowledge on courative value ORS? 1. Yes [Link]

7
[Link] the kind of work you 1. Yes [Link]
[Link] yes ,specify type of work _______________
[Link] hygiene (personal cleanlimess) 1. Yes [Link]
[Link] nutrition 1. Yes [Link]
4.1. If yes, are there forbidden foods 1. Yes [Link]
4.2. If yes, list the forhidden foods ________________
[Link] out why it is fortiddes _________________
4.4. Other precsution (s) _________________
[Link] you go to the near by health facility during pregnancy? 1. Yes [Link]
6. If yes to qoestion 5, mention when
[Link] getting sick [Link] regular chec-up 3. Other/speecify_____________
[Link] you make any special Prepoaction before pain starts that would make delivery easier? 1. Yes
[Link]
9. If yes to question 8, mantion the type of preparation you make__________________
10. Are there prohibited foods during puerperium? 1. Yes [Link]
11. If yes to question 10 list _____________________________________________
[Link] there recommended food during puerperium? 1. Yes [Link]
13. If yes to question 12 list _____________________________________________
II. child care practice
1. When do you wash the child after birth? ________________________________
2. When do you start breast-feeding after birth? ________________________________
3. For how long breast-feeding your baby(years)? ________________________________
[Link] what age do you start addition food for your baby? ________________________________
5. Are there forbidden foods for an infat? 1. Yes [Link]
6. If yes question 5, why? ________________________________
7. Are there recommended foods for an infat? 1. Yes [Link]
8. If yes to question 7, list the foods________________________________
9. If yes to question 7, why do you recommended these types of foods?______________
10. Do you use bottle for feeding your baby? 1. Yes [Link]
[Link] your under five child attend childrens clinic for cheokup? 1. Yes [Link]
12. If yes to question 11, where? ________________________________
13. which of the following do you practice on your children?
1. Uvula cutting
[Link] circumoision
[Link] of milk tooth
[Link]
5. Others (specfy)___________

8
[Link] you know the following rules for home treatment of diarboea?
 12.1. Give the child more fiuid then usual? 1. Yes [Link]
12.2. Continue feeding of the child? 1. Yes [Link]
13. Knowledge on signs of dehydration?
[Link] you know signs of dehydration? 1. Yes [Link]
13.2. If yes to question 13.1, specify _________________________
14. what is the major source of drinking water?
[Link] spring [Link] river
[Link] Spring [Link] well
[Link] river 6. Unprotected well
[Link] pipe/ up water [Link] water 9. Other _______________
[Link] the family boil water for drinking? 1. Yes [Link]
[Link] the household have latrines in the premlses?(by observation) 1. Yes [Link]
17. If yes to question 16, do most families(including children)use the latrine? 1. Yes [Link]
18. Does the family keep the latrine olean?(By observation) 1. Yes [Link]
[Link] the household garbage property disposed off? 1. Yes [Link]
(ie, at least once in a month ,buried, burnt)

S. Symptoms Presence Duration Treatment sough Kind of RX

N [Link] [Link] (Days) [Link] [Link] sough
1 Fever with skin rash that disappeared after few days
2 Chronic cough ,loos of weigh(with or withoutfever &
night sweating)
3 Paroxysmal cough with fever and a whoop
4 Acute cough with fever and moan/grunting and
shortness of breasthe
5 Locked jaw ,muscular spasms,with history of open
wound in an older or a recently born child(less then
one month)
6 Bye problem with or without discharge
7 Accidental injuries
8 Worms, such as Ascaries etc,in the stool
9 Diffionlty in food swallowing with fever and throat
problem
10 Joint pains with or without swelling(not caused by
injury

Other childhood illncesses

[Link] fail 4. Accidental poisoning
[Link]/attacks from animals [Link]/ other vehicle
3. [Link](Specify)____________

Part 1. EPI Coverage

To be filled for children 0-23 months of age
House hold information

[Link] [Link] [Link]

Kebele--------- Kebele---------
Woreda---------- Woreda----------
[Link] group [Link] [Link]
[Link] [Link]
[Link] [Link] explain_____________
[Link] education [Link] [Link] school(9-12)
[Link] school(1-8) [Link]/university
[Link] of nearest health facillity [Link] post [Link] center
[Link] [Link]
[Link] distance from closes health facility _________________minutes
6.Age______months D,O.B.________ [Link] [Link] [Link]
[Link] alive [Link] No

10
Part II Reasons fo non-immuniztion or failure(to be used with part I)
N.B; more than one answer is possible
[Link] the child was not vaccineted or he/she missed one dose,why?(Multiple choice allowed)
Lack of information General obstacls
[Link] was not aware of the EPT service I. Family was away
b. Family was aware of need to return for a further doses [Link]/mother was sick
c. Did not know the day and place to vaccine n. Family was not buy(example for food distribution or others)
[Link] Explain_____________________________ o. Family problem
Obstacles link with strategy Acceptabilty
[Link] of immunization was too far [Link] thinks immunization is useless
[Link] for vaccination inconvenient [Link] thinks immunization is harmuful due to
religious,cultural and bellevas againet vaccines
[Link] waiting time [Link]/she had side effects after first dose (only if the child
received only one dose)
[Link] service quality and eliability of the immunization [Link] scated by side effects
service(staff attiitude, lack of supply/ vaccines
[Link] of the vaccinator Other
[Link] brought the child but not given
[Link] was not gvailable [Link] Explain_____________________________
[Link] the child was not vaccinated(or missed a dose the day of the survey),does the family want to vaccinate him/he ( or
give him / her the seccond or third does)? [Link] 2. No
[Link] the child has not finished the schedule,does the
family know when and where the vaccination canbe
provied [Link] 2. No
20b. If yes ,where? 1. Health post [Link] Centre
2. Hospital [Link] ____________________

[Link] child receive a vaccination certificate for completing schedule for all [Link] 2. No
vaccination?

11

vaccination
[Link] card shown? 1. Yes [Link]
[Link] No vaccination card shown Why
3.1 Lost 1. Yes [Link]
3.2 Never received 1. Yes [Link]
 3.3 Others Explain------------------------

[Link]

PCV 1 1. Yes [Link] [Link] Know ( ) ( )

PCV 2 1. Yes [Link] [Link] Know ( ) ( )
PCV 3 1. Yes [Link] [Link] Know ( ) ( )
5. DPT= Hib-HePB

Penta 1 1. Yes [Link] [Link] Know ( ) ( )

Penta 2 1. Yes [Link] [Link] Know ( ) ( )
Penta 3 1. Yes [Link] [Link] Know ( ) ( )
[Link]
Dose
1 1. Yes [Link] [Link] Know ( ) ( )
1 1. Yes [Link] [Link] Know ( ) ( )
[Link](OPV)

At birth 1. Yes [Link] [Link] Know ( ) ( )

OPV 1 1. Yes [Link] [Link] Know ( ) ( )
OPV 2 1. Yes [Link] [Link] Know ( ) ( )
OPV 3 1. Yes [Link] [Link] Know ( ) ( )
14a Number of doses done in the community----------------
8. BCG

BCG 1 1. Yes [Link] [Link] Know ( ) ( )

15a BCG sCcar Present 1. Yes [Link]

[Link] A

1 1. Yes [Link] [Link] Know ( ) ( )

16a. Vitamin Areceived in the last 6 months 1. Yes [Link]
10. Where did you vacuinate your child 1 Health post [Link] 3. Health center 4. Mixed [Link]-----------

12

To be filled for womon

21. TT_________________
TT1 [Link] [Link] [Link] know ( ) ( )
TT1 [Link] [Link] [Link] know ( ) ( )
TT1 [Link] [Link] [Link] know ( ) ( )
TT1 [Link] [Link] [Link] know ( ) ( )
 TT1 [Link] [Link] [Link] know ( ) ( )
[Link] Toiold TT by history (the mother does not have vaccination card)
[Link] the pregnancy ,were you given air injection in the arm to prevat the baby
from getting tetsment, that it convvulsions after birth? 1. Yes [Link]
22b. During your pregnancy, how many times did you receive any tetanous injection? --------times
[Link] know
22c. At any time before this pregnancy, did you riceive any tetanous injection? 1. Yes [Link]
[Link] this pregnancy, how many other times did you reccive tetanous injection? --------times
[Link] know
22e. How many years ago did you receive the last tetanous injection, before this
pregnancy? _____ years
23. If the mother was not vaccinated or missed one does, why?(Multiple choice allowed)
Lack of information General obstacls
[Link] was not awere of the EPI service k. she was away
b. she was answere of need to return for further dokes I. she was sick
[Link] not know the day and place to vaccine [Link] was too busy(example for food
distrbution or otheres)
[Link] Explain_______________________ [Link] problem
Obstacles link with strategy Aceiptability
[Link] of immunization was too for o. She thinks immunization is useices
[Link] for vaccintion inconvenient p. She thinks immunization is harmfuldue to
religious,cultural believes against vaccines
[Link] wating time [Link] had side effects after first does (only if she
received only one does)
[Link] service quality and reliability of the immunization [Link] is spured side effects
service(staff attitude, lack of supply/vaccines
i. Absence of the vaccines Other
j. vaccines was not given [Link] Explain
[Link] did you get vaccinated? [Link] post [Link] center
[Link] 4. Others

Note- Ask only one question ,As why was the child not immunization or why was the child unabe to
Complets his/her vaccintion? Check mark (v)

13

Perceived morbldity
[Link] during the last two weeks

[Link] there anyone sick among the members of the family? [Link]
[Link]

2. I f yes ,specify member by:

 S.N Sex Age Allmeents (* )
[Link] [Link]
[Link] [Link]
[Link]
[Link]

(* ) Days lost from usual activity due to illness during this period

[Link] did you do?

1. Seek help from near by/distant

2. Health inst

3. Traditional healer

4. Self-treatment

5. Did nothing

6. Other specify

(** ) Includes any member of the family including children

14
vaccination
[Link] card shown? 1. Yes [Link]
[Link] No vaccination card shown Why
3.1 Lost 1. Yes [Link]
3.2 Never received 1. Yes [Link]
3.3 Others Explain------------------------

[Link]

PCV 1 1. Yes [Link] [Link] Know ( ) ( )

PCV 2 1. Yes [Link] [Link] Know ( ) ( )
PCV 3 1. Yes [Link] [Link] Know ( ) ( )
5. DPT= Hib-HePB

Penta 1 1. Yes [Link] [Link] Know ( ) ( )

Penta 2 1. Yes [Link] [Link] Know ( ) ( )
Penta 3 1. Yes [Link] [Link] Know ( ) ( )
[Link]
Dose
1 1. Yes [Link] [Link] Know ( ) ( )
1 1. Yes [Link] [Link] Know ( ) ( )
[Link](OPV)

At birth 1. Yes [Link] [Link] Know ( ) ( )

OPV 1 1. Yes [Link] [Link] Know ( ) ( )
OPV 2 1. Yes [Link] [Link] Know ( ) ( )
OPV 3 1. Yes [Link] [Link] Know ( ) ( )
14a Number of doses done in the community----------------
8. BCG

BCG 1 1. Yes [Link] [Link] Know ( ) ( )

15a BCG sCcar Present 1. Yes [Link]

[Link] A

1 1. Yes [Link] [Link] Know ( ) ( )

16a. Vitamin Areceived in the last 6 months 1. Yes [Link]
10. Where did you vacuinate your child 1 Health post [Link] 3. Health center 4. Mixed [Link]-----------

12