BANGLADESH
DIVISION:
DISTRICT:
THANA:
UNION OR WARD:
VILLAGE OR MOHALLA OR BLOCK:
CLUSTER NUMBER:
HOUSEHOLD NUMBER:
REGION:
DHAKA/CHITTAGONG OR SMALL CITY OR TOWN OR VILLAGE?
SMALL CITY 2
TOWN 3
VILLAGE 4
NAME OF THE HOUSEHOLD HEAD :
IS THIS HOUSEHOLD SELECTED FOR THE MEN'S SURVEY?
NO 2
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE
INTERVIEWER'S NAME
RESULT*
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY)
NEXT VISIT
DATE
TIME
FINAL VISIT
DAY
MONTH
YEAR
INTERVIEWER'S CODE
RESULT*
TOTAL NUMBER OF VISITS:
TOTAL PERSONS IN HOUSEHOLD:
TOTAL ELIGIBLE WOMEN:
TOTAL ELIGIBLE MEN:
LINE NUMBER OF RESPONDENT TO HOUSEHOLD SCHEDULE:
FIELD EDITOR
NAME
DATE
OFFICE EDITOR
KEYED BY
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 all 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.
Just to make sure that I have the complete listing:
1. Are there any other persons such as small children or infants that we have not listed?
NO
2. 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
3. Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?
NO
3. RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
02 WIFE OR HUSBAND
03 SON OR DAUGHTER
04 SON-IN-LAW OR DAUGHTER-IN-LAW
05 GRANDCHILD
06 PARENT
07 PARENT-IN-LAW
09 BROTHER OR SISTER
10 OTHER RELATIVE
11 ADOPTED OR FOSTER OR STEPCHILD
12 NOT RELATED
98 DON'T KNOW
4. SEX: Is (NAME) a male or female?
FEMALE 2
5. RESIDENCE: Does (NAME) usually live her?
NO 2
6. Did (NAME) sleep here last night?
NO 2
MARITAL STATUS FOR ALL AGED 10 OR ABOVE
8. What is the current marital status of (NAME)?
FORMERLY MARRIED (DIVORCED OR WIDOWED OR SEPARATED OR DESERTED) 2
NEVER MARRIED 3
9. WOMAN ELIGIBILITY: CIRCLE LINE NUMBER OF ALL EVER MARRIED WOMEN FROM QUESTION 8 CODES 1 AND 2.
FOR ALL MEN AGED 15-59
10. MAN'S ELIGIBILITY: IF HOUSEHOLD CHOSEN FOR MEN'S SURVEY, CIRCLE LINE NUMBER OF ALL CURRENTLY MARRIED MEN FROM QUESTION 8 CODE 1.
EDUCATION IF AGE 5 YEARS OR OLDER
11. Has (NAME) ever attended school?
NO 2 (GO TO 14)
12. What is the highest level of school (NAME) has attended? What is the highest class (NAME) has completed at that level?
2 SECONDARY
3 COLLEGE OR UNIVERSITY
8 DON'T KNOW
98 DON'T KNOW
13. Is (NAME) currently attending school?
NO 2
EMPLOYMENT IF AGE 5 YEARS OR OLDER
14. Is (NAME) currently working?
NO 2 (GO TO NEXT LINE)
15. Does (NAME) receive wages or income in cash or kind?
KIND 2
BOTH 3
NONE 4
18. What is the main 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 main 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
19A. Do you boil drinking water?
NO 2
20. What kind of toilet facility does your household have?
PIT LATRINE 22
OPEN LATRINE 23
HANGING LATRINE 24
OTHER (SPECIFY) 96
21. Do you share this facility with other households?
NO 2
22. Does your household (or any member of your household) have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
24. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
25. MAIN MATERIAL OF THE WALLS.
RECORD OBSERVATION.
TIN 32
26. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
27. Does your household own any homestead?
IF 'NO', PROBE: Does your household own homestead any other places?
NO 2
27A. Does your household own any land (other than the homestead land)?
NO 2 (GO TO 29)
28. How much land does your household own (other than the homestead land)?
DECIMALS ___
NONE 0000
29. In terms of household food consumption, how do you classify your household: deficit in whole year; somewhat deficit; neither deficit nor surplus; surplus.
SOMETIMES DEFICIT 2
NEITHER DEFICIT NOT SURPLUS 3
SURPLUS 4
30. Does your family have a vulnerable group feeding (VGF) card?
NO 2
31. Do you have any male or female member in this household who are receiving old age pension or widow or destitute benefit?
NO 2