1
For Caprivi, Namibia RAMP malaria survey (January 2012)
1. HOUSEHOLD QUESTIONNAIRE
No.
1
Variable
Response Scale
RAMP SURVEY HOUSEHOLD QUESTIONNAIRE
2
Consent obtained?
4
Yes
No (Skip to Q.39)
CLUSTER and HOUSEHOLD NUMBER questions follow next
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)
How many kilometres is your household from
the nearest health facility or hospital? (98=do
not know). If less than 1 km, put "1".
How many minutes does it take to walk to the
nearest health facility?
BEDNET questions follow next
3
8
9
10
11
12
13
Number of people of all ages who slept in this
household last night? (do NOT include usual
members of this household who slept
somewhere else last night)
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).
Has anyone visited this household in the last 6
months to talk about malaria or bednets?
Rural
Urban
Yes
No
Do not know
2
14
Has anyone in this household visited a health
facility where they discussed malaria or
bednets in the last 6 months?
15
In your opinion, what is the main cause of
malaria?
16
17
Yes
No
Do not know
 Mosquito bites
 Eating immature
sugarcane
 Eating watermelon
 Eating other dirty food
 Drinking dirty water
 Getting soeaked with
rain
 Cold or changing
weather
 Witchcraft
 Other
 Do not know
In your household, what is the main method
Sleep under a bednet
used to protect against getting malaria?
Sleep under an
insecticide-treated bednet
Use mosquito repellent
Take preventive
medication
Spray house with
insecicide
Keep house surroundings
clean
 Other
Do not know
What is your main source of information about
Radio
the use of bednets?
Health facility
Community based
volunteer
Community leader
Neighbour
Relative
 Television
Other
No information
3
19
Indoor Residual Spraying (IRS) question
follows next
At any time in the past 12 months, has anyone
sprayed the interior walls of your dwelling
against mosquitoes?
20
21
HOUSEHOLD ASSET questions follow next
Does your household have electricity?
22
Radio?
Yes
No
23
Television?
Yes
No
24
Refrigerator?
Yes
No
25
Electric iron?
Yes
No
26
Electric fan?
Yes
No
27
Bicycle?
Yes
No
28
Motorcycle or scooter?
Yes
No
29
Car or truck?
Yes
No
30
Cattle, goat or sheep?
Yes
No
31
Canoe or boat?
Yes
No
32
Phone?
Yes
No
33
Domestic worker (unrelated to head of household)?
Yes
No
34
Do members of this household work on agricultural land
OWNED BY themselves or their family?
Yes
No
18
Yes
No
Do not know
Yes
No
4
35
What is the principal household source of drinking water?
Tap 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
36
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
Shared improved pit latrine

Bush or field
Other
37
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
Carpeted
Other
38
What is the principal type of cooking fuel in your house?
39
This portion of the interview is complete. Close this questionnaire by clicking "Finish for now" on
the next screen. If consent was NOT obtained, proceed to the next household.
If consent was obtained, proceed to the Persons Roster questionnaire.
Wood or dung
Kerosene
Charcoal
Electricity
Gas
 Solar
Before starting the Persons Roster questionnaire, complete the TOP part of the paper
job aid called Persons Roster/Who slept under which net last night (the section on Persons
Roster)
5
2. PERSONS ROSTER QUESTIONNAIRE
No.
1
Variable
Response scale
PERSONS ROSTER. Ask about the persons who slept here last night, including non-family
members. Start with the head of HH or oldest person. Do NOT include usual members of the HH if
they DID NOT sleep here last night.
2
Cluster number (same as in Household questionnaire)
3
Household number (same as in Household questionnaire)
4
5
Name of the person
Line number of the person in the household (Obtain this
from paper Persons Roster, column 1, Person Number)
6
Gender
7
Age in YEARS? Mark zero (0) if less than 12 months old.
(Estimate if they do not know, especially for adults)
Male
Female
(IF ≥5 years skip to Q.16)
Yes
No (skip to Q. 16)
Do not know (skip to Q. 16)
8
Did the child <5 years old have a fever in the last two
weeks?
9
What was done for the child that had fever?
10
Did the child with fever receive a finger or heel stick
for blood testing for malaria?
11
Did the child test positive for malaria?
12
Did the child with fever receive ANY malarial drugs
for the fever?
Yes
No (skip to Q. 16)
Do not know
13
Did the child with fever receive ACT for the treatment
of fever?
Yes
No (skip to Q. 15)
Do not know
14
Did the child with fever receive ACT within 24 hours
of having a fever?
Yes
No (skip to Q.16)
Do not know
 No treatment
 Treated at home
 Taken to health facility
 Taken to a chemist or private
practitioner
 Taken to a traditional medicine
person
 Yes
 No
 Do not know
 Yes
 No
 Do not know
6
15
If the child with fever received some malaria drug but
not ACT, what was the other malaria drug?
Chloroquine
SP_Fansidar
- Quinine
- Others
- Do not know
16
IF there IS another person who 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 the Net Roster questionnaire.
 Before starting the Net Roster questionnaire, complete the BOTTOM part of the paper
job aid called Persons Roster/Who slept under which net last night (the section on Who
slept under which net last night)
7
3. NET ROSTER QUESTIONNAIRE
No.
1
2
Variable
Response scale
ROSTER OF NETS. I would like to ask you about each 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.)
Cluster number (same as in Household questionnaire)
3
Household number (same as in Household questionnaire)
4
INTERVIEWER ONLY: Which net are you collecting
information about? If the first net PUT number 1, if the
second net PUT number 2, etc. (Use consecutive numbers)
INTERVIEWER ONLY: Ask if you can see this net. Did
you observe the net?
5
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 net?
(RECORD IN MONTHS. Put "36" for 3 yrs, "48" for 4 yrs,
and "60" for >=5yrs. 98=NOT SURE)
8
LLIN (long-lasting insecticide-treated net): is a factory treated net that does not require any further
treatment.
9
From where did you obtain this net?
 Mass distribution in a settlement
camp in 2011
 Other mass distribution
Market/Retail shop
Health facility
Pharmacy
Friend/relative
Other
10
Brand of the net? (Observe or ask for the brand of net. If the
brand is unknown, and you cannot observe the net, show
pictures of typical net types/brands to respondent)
Permanet
Dawa
Tana
 SuperNet Plus
 Other LLIN
Other non-LLIN
Do not know brand
11
Did anyone sleep under this net last night?
Yes
No (skip to Q.17)
Not sure
8
12
Line number of the first person that slept under this net. (Get
this from the paper job aid “Persons Roster”)
13
Line number of the second person that slept under this net.
(Get this from the paper job aid “Persons Roster”)
14
Line number of the third person that slept under this net.
(Get this from the paper job aid “Persons Roster”)
15
Line number of the fourth person that slept under this net.
((Get this from the paper job aid “Persons Roster”)
16
Line number of the fifth person that slept under this net.
(Get this from the paper job aid “Persons Roster”)
17
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.
9
JOB AID
Person roster and who slept under which net last night
Instructions for interviewer:
*ONLY record the names of people who slept in the household the previous night. This should NOT include all family members (if one of them
slept somewhere else) and it CAN include people who are NOT family members, eg., friends, temporary visitors or domestic servants).
*Start with the head of the household. If the head of the household DID NOT sleep here last night, start with the oldest person.
CVC
Cluster number:
CVC
Household number:
Date:
Interviewer:
Person number
Name
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
WRITE the person number from above into their box below. We want to know which people slept under which net last night. For
each net, list the name and person number that slept under each net last night (moving down the column).
Net 1
Net 2
Net 3
Net 4
Net 5 *
Description of net (memory device
only)
Description of net
Description of net
Description of net
Description of net
Name:
Name:
Name:
Name:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Name:
Person number:
Person number:
Person number:
Person number:
Person number:
NOTE: ONLY the person NUMBER (data inside the boxes) is entered into the mobile phone.
* If more than five (5) nets are owned by the household use another sheet.