MANAGEMENT SURVEY—QUESTIONNAIRE PAPER TRAINING TOOL

①HOUSEHOLD QUESTIONNAIRE

No. / Variable / Response Scale
1 / MANAGEMENT SURVEY
2 / Consent obtained? / Yes
No (Skip to Q.38)
3 / CLUSTER and HOUSEHOLD questions follow next
4 / Cluster number /
5 / Household number /
6 / Name of head of household /
7 / Household in a rural or urban area?(Urban defined as a town with >=5000 persons) / Rural
Urban
8 / How many kilometers is your household from the nearest government, NGO, or mission health facility or hospital? (98=do not know). If less than 1 km, put “1”. /
9 / How many Minutes does it take to walk to the nearest health facility? /
10 / BEDNET questions follow next
11 / Number of people of all ages who slept in this household last night? (do NOT include usual members of this household that slept somewhere else last night) /
12 / Last night, how many sleeping spaces were there (both inside and outside if someone slept outside)? (Sleeping space defined as a place where people sleep that could be covered by a single net). /
13 / Has anyone visited this household in the last 6 months to talk about malaria or mosquito nets? / Yes
No
Do not know
14 / Has anyone in your household visited the health facility in the last 6 months? / Yes
No(Skip to Q16)
Do not know
15 / Has anyone in this household talked with people at the clinic or hospital about malaria or mosquito nets in the last 6 months? / Yes
No
Do not know
16 / What is your greatest source of information on the use of mosquito nets? / Radio
Health centre staff
Community based volunteer
Community leader
Neighbor
Relative
Other
No information
17 / Indoor Residual Spraying (IRS) question follows next
18 / At any time in the past 12 months, has anyone sprayed the interior walls of your dwelling against mosquitoes? / Yes
No
Do not know
19 / HOUSEHOLD ASSET questions follow next
20 / Does your household have electricity? / Yes
No
21 / Radio? / Yes
No
22 / Television? / Yes
No
23 / Refrigerator? / Yes
No
24 / Electric iron? / Yes
No
25 / Electric fan? / Yes
No
26 / Bicycle? / Yes
No
27 / Motorcycle or scooter? / Yes
No
28 / Car or truck? / Yes
No
29 / Cow, goat, or sheep? ? / Yes
No
30 / Canoe or boat / Yes
No
31 / Phone? / Yes
No
32 / Domestic worker (unrelated to head of household)? / Yes
No
33 / Do members of this household work on agricultural land belonging to themselves or their family? / Yes
No
34 / What is the principal household source of drinking water? / Piped water into residence
Protected well in residence
Unprotected well in residence
Open well in yard
Protected well in yard
Unprotected public well
Protected public well
Tap in yard
Tanker truck
Bottled water
Public tap
Rain water
Surface water (e.g., river, lake)
Spring

35 / What is the principal type of toilet/sanitary facility used by members of your household? / Own flush toilet
Shared flush toilet
Own pit latrine
Own improved pit latrine
Shared pit latrine
Bush or field
Other
36 / What is the principal type of flooring in your house (interviewer may choose to observe)? / Dirt or sand
Dung /wood / palm/ bamboo
Cement including vinyl
Cement including parquet
Tile (e.g., ceramic, marble)
Car Carpeted
 Other
37 / What is the principal type of cooking fuel in your house? / Wood or dung
Kerosene
Charcoal
 Electricity
LPG gas
38 / This portion of the interview is complete. Close this questionnaire by clicking the option "Finish for now" on the next screen.If consent was NOT obtained, proceed to the next household.
If consent was obtained, please proceed to the 'Person Roster ' questionnaire.

②PERSON ROSTER AND TREATMENT/TESTING OF CHILDREN

No. / Variable / Response Scale
1 / ROSTER OF PERSONS. Ask about persons slept here last night, including those NOT family members. Do NOT include usual household members if they DID NOT sleep here last night. Keep your paper job aid handy.
2 / Cluster number (same as in Household questionnaire) /
3 / Household number (same as in Household questionnaire) /
4 / Name of the person /
5 / Line Number of the person in the household(Obtain this frompaper Person Roster, column 1) /
6 / Gender / Male
Female
7 / Age in YEARS—Markzero(0) if less than 12 months old. (Estimate if they do not know, especially for adults) / (IF ≥5 years skip to Q.16)
8 / Did the child <5 years old have a fever in the last two weeks? / Yes
No (skip to Q. 19)
Do not know (skip to Q. 19)
9 / What was done for the child that had fever? / Nothing
Treated at Home
Taken to a health facility
Taken to church
Taken to a chemist (PMVs)
Taken to a native doctor
10 / Did the child with fever receive ANY malaria drugs for the fever? / Yes
No (skip to Q. 15)
Do not know
11 / Did the child receive the malaria drugs within 24 hours of having a fever? / Yes
No
Do not know
12 / Did the child with fever receive ACT for the treatment of fever? / Yes
No (skip to Q. 14)
Do not know
13 / Did the child with fever receive ACT within 24 hours of onset of the fever? / Yes
No
Do not know
14 / If the child with fever received some malarial drug but not ACT, what was the other malaria drug? / Chloroquine
SP_Fansidar
- Quinine
- Other
Do not know
15 / Did the child with fever receive a finger or heel stick for blood for testing for malaria? / Yes (skip to Q. 19)
No (skip to Q. 19)
Do not know (skip to Q. 19)
16 / Pregnant: If this person is female from 15 to 49 years is she pregnant? / Yes
No or do not know (skip to Q.19)
17 / Has this woman started her Ante Natal Care (ANC) at the health facility? / Yes
No or do not know (skip to Q.19)

18 / Has this woman received any malarial drugs for the prevention of malaria during her ANC visit? / Yes
No
19 / IF there ISanother person slept here last night click “Add New Record” on the next screen. IF there are NO MORE people, close this questionnaire by clicking option” Finish for now” on the next screen. Then, proceed to “Net Roster” questionnaire.

③NET ROSTER

No. / Variable / Response Scale
1 / ROSTER OF NETS. I would like to ask you about each mosquito bednet that you have in the household (includes all nets that were owned and present in the household last night—Interviewer must enter a new record for each net)
2 / Cluster number (same as in Household questionnaire) /
3 / Household number (same as in Household questionnaire) /
4 / INTERVIEWER ONLY: What net are you collecting information about? If the first net PUT number 1, if the second net PUT number 2, etc. (use consecutive numbers) /
5 / INTERVIEWER ONLY: Ask if you can see this net. Did you observe the net? / Yes
No
6 / Was this net hung last night? (Look for evidence of hanging and observe or ask if the net was hanging) / Yes
No
Do not know
7 / How many months ago did your household obtain the mosquito net? (RECORD IN MONTHS. Put "36" for 3 yrs, "48" for 4 yrs, and "60" for >=5yrs. 98=NOT SURE) /
8 / LLIN(long-lasting insecticidal net) is a factory treated net that does not require any further treatment.
Pretreated is a net that has been pretreated with an insecticide and requires further treatment after 6-12 months
9 / From where did you obtain this net? / Door-to-door campaign 2011
MaMasscampaign 2008
Market/Retail shop
Health facility
Pharmacy
Friend/Relative
Other
10 / Brand of the net? (Observe or ask for the brand of mosquito net. If the brand is unknown, and you cannot observe the net, show pictures of typical net types/brands to respondent) / LLIN-Dawa(skip to Q.14)
LL LLIN- Permanet (skip to Q.14)
Other LLIN (skip to Q.14)
 Pre-treated or treated net
Other
Do not know brand
11 / When you got the net, was it already factory-treated with an insecticide to kill or repel mosquitoes? / Yes
No
Not sure
12 / Since you got the mosquito net, was it ever soaked or dipped in a liquid to repel mosquitoes or bugs? / Yes
No(skip to Q.14)
Not sure
13 / How many months ago was the net last soaked or dipped in a liquid to repel mosquitoes or bugs? (RECORD IN MONTHS. IF< 1 MONTH AGO, PUT 0 months, PUT "36" for 3 y, "48" for 4 y, and "60" for >=5y. 98=NOT SURE) /
14 / Did anyone sleep under this mosquito net last night? / Yes
No (skip to Q.20)
Not sure
15 / Line number of the first person that slept under this net.
(Get this from the paper job aid “Person Roster”) /
16 / Line number of the second person that slept under this net.
(Get this from the paper job aid “Person Roster”) /
17 / Line number of the third person that slept under this net.
(Get this from the paper job aid “Person Roster”) /
18 / Line number of the fourth person that slept under this net.
(Get this from the paper job aid “Person Roster”) /
19 / Line number of the fifth person that slept under this net. (Get this from the paper job aid “Person Roster”) /
20 / IF there is another bednet in the household click “Add New Record” on the next screen. IF there are NO MORE bednets, close this questionnaire by clicking "Finish for now". Proceed to the next household.

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