MINISTRY OF PLANNING FINANCE AND OF INTERNATIONAL COOPERATION
CENTRAL AFRICAN REPUBLIC
DEMOGRAPHIC AND HEALTH SURVEY
NAME OF PREFECTURE____
SUB-PREFECTURE____
TOWN____
URBAN OR RURAL
RURAL 2
CLUSTER NUMBER____
VILLAGE/NEIGHBORHOOD____
HOUSEHOLD NUMBER____
NAME OF HEAD OF HOUSEHOLD____
NO 2
LINE NUMBER OF PERSON INTERVIEWED FOR HOUSEHOLD QUESTIONNAIRE____
INTERVIEWER'S NAME____
RESULT*
FINAL VISIT
DAY____
MONTH____
YEAR____
NAME____
RESULT
NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT RESPONDENT AT HOME AT TIME OF VISIT 2
ENTIRE HOUSEHOLD ABSENT FOR EXTENDED PERIOD OF TIME 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____
TOTAL NO. OF VISITS____
TOTAL IN HOUSEHOLD____
TOTAL ELIGIBLE WOMEN____
TOTAL ELIGIBLE MEN____
FRENCH QUESTIONNAIRE
LANGUAGE OF INTERVIEW
SANGO 2
OTHER (SPECIFY)____ 3
NO 2
FIELD EDITOR
NAME____
DATE____
OFFICE EDITOR____
KEYED BY____
HOUSEHOLD SCHEDULE
Now we would like 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 name of the persons who usually live in your household and guests of the household who stayed here last night, starting with the head of the household.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD*
What is the relationship of (NAME) to the head of household?
WIFE OR HUSBAND 2
SON OR DAUGHTER 3
SON-IN-LAW OR DAUGHTER-IN-LAW 4
GRANDCHILD 5
PARENT 6
PARENT-IN-LAW 7
BROTHER OR SISTER 8
CO-WIFE 9
NEPHEW/NIECE 10
OTHER RELATIVE 11
NOT RELATED 12
DON'T KNOW 98
RESIDENCE
4) Does (NAME) usually live here?
NO 2
5) Did (NAME) stay here last night?
NO 2
Sex
6) Is (NAME) male or female?
FEMALE 2
EDUCATION
IF AGE 5 YEARS OR OLDER
8) Has (NAME) ever been to school?
NO 2
IF ATTENDED SCHOOL
9) What is the highest level of education that (NAME) attended?
What was the highest grade that he or she completed at this level?
SECONDARY 2
HIGHER 3
DON'T KNOW 8
DON'T KNOW 98
10) IF AGE LESS THAN 25 YEARS
Is (NAME) still in school?
NO 2
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OLD. THESE QUESTIONS REFER TO BIOLOGICAL PARENTS OF THE CHILD. RECORD 00 IF THE PARENTS ARE NOT MEMBER OF THE HOUSEHOLD.
11) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
12) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name? RECORD THE MOTHER'S LINE NUMBER
13) Is (NAME)'s natural father still alive?
NO 2
DON'T KNOW 8
14) IF ALIVE: does (NAME)'s natural father live in this household?
IF YES: what is his name? MARK THE FATHER'S LINE NUMBER
15A) WOMEN'S ELIGIBILITY
CIRCLE THE LINE NUMBER OF WOMEN ELIGIBLE FOR THE INDIVIDUAL SURVEY
15B) MEN'S ELIGIBILITY
CIRCLE THE LINE NUMBER OF MEN ELIGIBLE FOR THE INDIVIDUAL SURVEY
TICK HERE IF CONTINUATION SHEET USED____
TOTAL NUMBER OF ELIGIBLE WOMEN____
TOTAL NUMBER OF ELIGIBLE MEN____
Just to make sure that I have a complete listing:
1) Are there any other people such as small children or infants who 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 that have not been listed?
NO
16) What is the main source of drinking water for members of your household?
PUBLIC TAP 12
WELL OUTSIDE OF YARD 22
BASIC WELL 22
DRILL HOLE/PUMP 23
RIVER/STREAM 32
POND/LAKE 33
DAM 34
TANKER TRUCK 51
BOTTLED WATER 61 (GO TO 18)
17) How long does it take to go there, get water, and come back?
ON PREMISES 996
18) What kind of toilet facility does your household have?
SHARED FLUSH TOILET 12
VENTILATED IMPROVED PIT (VIP) LATRINE 22
OTHER (SPECIFY) 96
NO 2
NO 2
NO 2
NO 2
NO 2
20) How many rooms in your household are used for sleeping?
21A) MAIN MATERIAL OF ROOF
RECORD OBSERVATION
STRAW 12
SHEET METAL 22
21B) MAIN MATERIAL OF WALLS
RECORD OBSERVATION
PLANKS 22
BRICKS 32
21C) MAIN MATERIAL OF THE FLOOR
RECORD OBSERVATION
CEMENT 32
22) Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
23) What type of salt is usually used for cooking in your household?
(ASK TO SEE SALT PACKAGE)
PACKAGED SALT (IODIZED) 02
PACKAGED SALT (NOT IODIZED) 03
SALT FOR ANIMALS 04
LOOSE SALT 05
OTHER (SPECIFY)____ 96