Name of Operational District
Name of health center
Code of village
Household ID code
Number of household members
electricity
a radio?
a television?
a mobile telephone?
If yes, is it a smartphone?
a refrigerator?
a wardrobe?
a sewing machine or loom?
CD/DVD player?
a generator/battery/solar panel?
a watch?
a bicycle or cyclo?
a motorcycle or motor-scooter?
a motorcycle-cart
a oxcart or horsecart?
a car or truck, tractor or van?
a boat with a motor?
a boat without a motor?
any agricultural land?
any livestock, herds, other farm animals, or poultry?
a bank account?
What is the main material of the floor?
What is the main material of the roof?
What is the main material of the exterior walls?
How many rooms in this household are used for sleeping?
What is the main source of drinking water during the wet season for members of y
What is the main source of drinking water during the dry season for members of y
Do you do anything to the water to make it safer to drink?
What do you usually do to make the water safer to drink?
Boil
Strain through a cloth
Add bleach/chlorine
Solar disinfection
Use water filter (ceramic/sand/composite/etc.)
Let it stand and settle
What kind of toilet facility do members of your household usually use?
Past month, any member of the household ill or injured?
If yes, how many persons, including you?
code of las hh member who sick
Past 12 months, any member hospitalized?
Family planning services
Antenatal care
Normal delivery and associated services
Postnatal care
Vaccination services for women and children
name_datacollector
[Last sick member] seek care for illness/injury?
If Yes, how many times?
Where did [Last sick member] seek care for the FIRST TIME?
Where did [Last sick member] seek care for the LAST TIME?
How much did [Last sick member]  spend for care and treatment?
Did [Last sick member]  receive any financial support from HEF/NSSF for care and
Household income
Savings
Borrowing or using loan
Selling assets
Selling household production in advance
other
If No, any self-medication at home?
Where was [Last sick member] hospitalized for the LAST TIME?
How much did [Last sick member] spend for the hospitalization?
Did [Last sick member] receive any financial support from HEF/NSSF for hospitali
Specified others
Where did [NAME] seek the indicated preventive care for the LAST TIME?
How much did [Last sick member]spend for the preventive care?
Did [Last sick member] receive any financial support HEF/NSSF for preventive car