DIVISION:
DISTRICT:
THANA:
UNION OR WARD:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE?
SMALL CITY 2
TOWN 3
VILLAGE 4
NAME OF HOUSEHOLD HEAD:
IS THE HOUSEHOLD SELECTED FOR MEN'S SURVEY?
NO 2
FIRST VISIT
DATE INTERVIEWER'S NAME
RESULT*
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
SECOND VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
NEXT VISIT
DATE
TIME
THIRD VISIT
DATE
INTERVIEWER'S NAME
RESULT*
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD 3
POSTPONED 4
REFUSED 5
DWELLING VACANT OR ADDRESS NOT A DWELLING 6
DWELLING DESTROYED 7
DWELLING NOT FOUND 8
OTHER (SPECIFY) 9
FINAL VISIT
DAY
MONTH
FEBRUARY 02
MARCH 03
APRIL 04
MAY 05
JUNE 06
JULY 07
AUGUST 08
SEPTEMBER 09
OCTOBER 10
NOVEMBER 11
DECEMBER 12
YEAR 199_
CODE
RESULT
TOTAL NUMBER OF VISITS
TOTAL IN HOUSEHOLD
TOTAL ELIGIBLE WOMEN
TOTAL ELIGIBLE MEN
LINE NUMBER OF RESPONDED TO HOUSEHOLD SCHEDULE
NAME
DATE
OFFICE EDITED BY
KEYED BY
KEYED BY
HOUSEHOLD SCHEDULE
Now we would like some information about the people who usually live in your household or who are staying with you now.
1. LINE NUMBER:
2. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household and guest of the household who stayed here last night, starting with the head of the household?
3. RELATIONSHIP TO HEAD HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE 02
SON OR DAUGHTER 03
SON OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
OTHER RELATIVE 09
ADOPTED OR FOSTER CHILD 10
NOT RELATED 11
DOES NOT KNOW 98
Just to make sure that I have a complete listing:
4. Are there any other persons such as small children or infants that we have not listed?
NO
5. In addition, are there any other people who may not be members of your family, such as domestic servants, lodgers or friends who usually live here?
NO
6. Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO
7. RESIDENCE: Does (NAME) usually live here?
NO 2
8. Did (NAME) sleep here last night?
NO 2
9. SEX: Is (NAME) male or female?
FEMALE 2
EDUCATION IF AGED 6 YEARS OR OLDER
11. Has (NAME) ever been to school?
NO 2
IF ATTENDED SCHOOL
12. What is the highest level of school (NAME) attended? What is the highest class (NAME) completed at that level?
SECONDARY 2
COLLEGE OR UNIVERSITY 3
DOES NOT KNOW 8
DOES NOT KNOW 98
IF AGED LESS THAN 25 YEARS
13. Is (NAME) still in school?
NO 2
MARITAL STATUS FOR ALL AGED 10 YEARS OR ABOVE
14. Has (NAME) ever been married?
NO 2
15. WOMEN ELIGIBILITY: CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN AGE 10-49.
16. HUSBAND' LINE NUMBER: WRITE THE LINE NUMBER OF THE HUSBAND OF THOSE IN (15).
IF NOT MARRIED OR IF HUSBAND NOT IN HOUSEHOLD, WRITE '00'.
17. MAN'S ELIGIBILITY: IF HOUSEHOLD CHOSEN FOR MEN'S SURVEY, CIRCLE LINE NUMBER OF ALL EVER MARRIED MEN AGE 15-59.
18. What is the source of water your household uses for dishwashing?
PIPED OUTSIDE DWELLING 12
SURFACE WELL OR OTHER WELL 22
RIVER OR STREAM 32
OTHER (SPECIFY) 96
19. What is the source of drinking water for members of your household?
PIPED OUTSIDE DWELLING 12
SURFACE WELL OR OTHER WELL 22
RIVER OR STREAM 32
OTHER (SPECIFY) 96
20. What kind of toilet facility does your household have?
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
OTHER (SPECIFY) 96
21. Where do adult women in your household usually defecate?
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
OTHER (SPECIFY) 96
22. Where do children in your household usually defecate?
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
OTHER (SPECIFY) 96
NO CHILDREN 97
23. Does your household have electricity?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
25. Does any member of your household own agricultural land?
NO 2
26. In the last 2 weeks, has anyone in your household been to any health facility or been to see a doctor or nurse for any reason?
NO 2 (GO TO 29)
FAMILY WELFARE CENTRE 12
THANA HEALTH COMPLEX 13
SATELLITE OR EPI CLINIC 14
TRADITIONAL DOCTOR 22
PHARMACY 23
FRIENDS OR RELATIVES 32
OTHER (SPECIFY) 96
DOES NOT KNOW 98
28. What was the reason for the visit?
FAMILY PLANNING 12
ANTENATAL CHECKUP 13
ACCIDENT 22
29. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
30. MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.
TIN 32
31. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
32. IS THIS HOUSEHOLD IN A BOSTI (SLUM)?
RECORD OBSERVATION.
NO 2