Ministry of Territory Planning and Development
Republic of Cameroon
"Peace-Work-Country"
IDENTIFICATION
PROVINCE __________
DEPARTMENT __________
URBAN DISTRICT/DISTRICT __________
CITY/COUNTY/GROUP __________
VILLAGE __________
NEIGHBORHOOD/TOWN __________
NAME OF RESPONDENT __________
PROVINCE ____
STRATUM NUMBER _______
URBAN DISTRICT/DISTRICT _________
CLUSTER NUMBER _____
STRUCTURE NUMBER _________
HOUSEHOLD NUMBER ________
NUMBER OF COUNTING ZONE_______
NO 2
INTERVIEWER 1
(REPEAT FOR SECOND AND THIRD INTERVIEWERS)
DATE__
DAY__
MONTH__
YEAR__
INTERVIEWER NAME___
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 [FOR INTERVIEWERS 1 AND 2]
DATE__
TIME__
FINAL VISIT
DAY__
MONTH__
YEAR 19__
INTERVIEWER__
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
TOTAL PERSONS IN HOUSEHOLD ___
TOTAL ELIGIBLE WOMEN ___
TOTAL ELIGIBLE MEN ___
LINE NO. OF SURVEYED HOUSEHOLD ___
NO. OF QUESTIONNAIRE ___
NO. OF QUESTIONNAIRES ___
FIELD EDITOR
NAME__
DATE__
OFFICE EDITOR__
KEYED BY___
0) RECORD TIME
MINUTE ___
NO 2
Now we would like information about the people who usually live in your household or who are staying with you now.
2) FIRST AND LAST NAME:
Please give me the name of the people 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 THE HEAD OF THE HOUSEHOLD: What is the relationship of (name) to the head of household?
WIFE OR HUSBAND 02
SON OR DAUGHTER 03
SON OR DAUGHTER IN LAW 04
GRANDCHILD 05
PARENT 06
PARENT IN LAW 07
BROTHER OR SISTER 08
UNCLE OR AUNT 09
COUSIN/NIECE/NEPHEW 10
OTHER RELATIVE 11
NOT RELATED 12
DK 13
4) RESIDENCE STATUS: Does (name) usually live here?
NO 2
5) RESIDENCE STATUS: Did (name) sleep here last night?
NO 2
6) SEX: Is (NAME) male or female?
FEMALE 2
8) EDUCATION: Does (NAME) know how to read and write?
NO 2
9) EDUCATION: Has (NAME) ever been to school?
NO 2 (GO TO 12)
What is the highest level of school (name) attended?
What is that highest grade (name) completed) at this level?
IF THE LEVEL IS NURSERY SCHOOL, DO NOT WRITE ANYTHING FOR GRADE.
LEVEL
PRIMARY 1
HIGHER 2
SUPERIOR 3
DK 4
GRADE
STANDARD ONE/CLASS TWO/CP 2
STANDARD TWO/CLASS THREE/CE1 3
STANDARD THREE/CLASS FOUR/CE2 4
STANDARD FOUR/CLASS FIVE/CM1 5
STANDARD FIVE/CLASS SIX/CM2 6
STANDARD SIX/CLASS SEVEN 7
FORM 2/FIFTH/2ND YEAR 2
FORM 3/FOURTH/3RD YEAR 3
FORM 4/THIRD/4TH YEAR 4
FORM 5/SECOND 5
LOWER SIXTH FORM/FIRST 6
UPPER SIXTH FORM/FINAL 7
IF AGED LESS THAN 25 YEARS:
11) EDUCATION: Is (NAME) still in school?
NO 2
FOR THOSE LESS THAN 15 YEARS OF AGE:
12) SUPERVISION OF CHILDREN: Is (NAME)'s natural mother alive?
NO 2 (GO TO 14)
DK 8 (GO TO 14)
Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER.
THIS QUESTION REFERS TO THE BIOLOGICAL PARENTS OF THE CHILD. RECORD '00' IF THE PARENT IS NOT A MEMBER OF THE HOUSEHOLD.
14) Is (NAME)'s natural father alive?
NO 2 (GO TO 16)
DK 8 (GO TO 16)
15) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: what is his name?
RECORD FATHER'S LINE NUMBER.
THIS QUESTION REFERS TO THE BIOLOGICAL PARENTS OF THE CHILD. RECORD '00' IF THE PARENT IS NOT A MEMBER OF THE HOUSEHOLD.
16) WOMEN IN A UNION: Is (NAME) married or currently living with partner?
NO 2
17) ELIGIBILITY OF WOMEN: CIRCLE THE ORDER NUMBER OF THE WOMEN (SEE 7) WHO SLEPT IN THE HOUSEHOLD LAST NIGHT (YES TO 5).
18) ELIGIBILITY OF HUSBANDS: Does the husband/partner normally live in this household?
IF YES: what is his name?
(FOR EACH ELIGIBLE WOMAN IN A UNION)
RECORD THE LINE NUMBER OF THE HUSBAND IN FRONT OF THAT OF HIS WIFE. IF NONE, RECORD '00' IN FRONT OF THE LINE NUMBER OF HIS WIFE.
TICK HERE IF CONTINUATION SHEET USED
TOTAL NUMBER OF ELIGIBLE WOMEN
Just to make sure that I have a 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 or friends who normally live in your household?
NO ___
3. Do you have any guests or temporary visitors, or anyone else who slept here last night?
NO __
19) What is the source of water to wash the dishes, to wash clothes, and to bathe?
PIPED INTO YARD 12 (GO TO 21)
PIPED INTO NEIGHBOR'S YARD 13
PUBLIC TAP 14
WELL WITHOUT PUMP 22
20) How long does it take to go there, get water, and come back?
IF 90 MINUTES OR LESS, RECORD THE MINUTES. IN OTHER CASES, RECORD IN HOURS.
HOURS: ___ 2
ON PREMISES 996
21) Does your household get drinking water from this same source?
NO 2
22) What is the source of drinking water for members of your household?
PIPED INTO YARD 12 (go to 24)
PIPED INTO NEIGHBOR'S YARD 13
PUBLIC TAP 14
WELL WITHOUT PUMP 22
23) How long does it take you to go there, get water, and come back?
IF 90 MINUTES OR LESS, RECORD IN MINUTES. IN OTHER CASES, RECORD IN HOURS.
HOURS: ___ 2
ON THE PREMISES 996
24) What kind of toilet facility does your household have?
VENTILATED IMPROVED PIT (VIP) LATRINE 22
RIVER 32
NO TOILET 33
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26) How many rooms in your household are used for sleeping?
27) How many people sleep in the room that sleeps the most people?
28) MAIN MATERIAL OF THE FLOOR.
(RECORD OBSERVATION)
TILE 32
29) Does someone in your household own:
NO 2
NO 2
NO 2
MINUTES: ___