HOUSEHOLD SCHEDULE
GOVERNORATE __________
PSU/SEGMENT NO. _____________
KISM/MARKAZ __________
BUILDING NO. ________________
SHIAKHA/VILLAGE __________
HOUSE NO. ___________
URBAN 1
RURAL 2
HOUSEHOLD NUMBER ___________
MATERNAL MRT/ANTHROPOMETRY SUBSAMPLE
NO 2
NAME OF HOUSEHOLD HEAD _______________
ADDRESS IN DETAIL ______________
GOVERNORATE ____
PSU/SEGMENT NO. ____
HOUSEHOLD NO. ____
SUBSAMPLE ____
INTERVIEWER VISITS 1
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES)
RESULT* ______
NEXT VISIT:
DATE _____
TIME ________
INTERVIEWER VISITS 2
DATE _____
TEAM _____
INTERVIWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES)
RESULT* ______
NEXT VISIT:
DATE _____
TIME ________
INTERVIEWER VISITS 3
DATE _____
TEAM _____
INTERVIWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES)
RESULT* ______
NEXT VISIT:
DATE _____
TIME ________
FINAL VISIT
MONTH ____
YEAR ____
TEAM _____
INTERVIEWER'S NAME _____
LENGTH OF HOUSEHOLD INTERVIEW (MINUTES) ____
RESULT*____
TOTAL NUMBER OF VISITS ____
TOTAL IN HOUSEHOLD ____
TOTAL ELIGIBLE WOMEN ____
2 HOUSEHOLD PRESENT BUT NO COMPETENT RESP. AT HOME
3 HOUSEHOLD ABSENT NIGHT BEFORE INTERVIEW
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) ___________
FIELD EDITOR
NAME _________
DATE _________
SIGNATURE __________
OFFICE EDITOR
NAME _________
DATE _________
SIGNATURE __________
CODER
NAME _________
DATE _________
SIGNATURE __________
DATA ENTRY OPERATOR
NAME _________
DATE _________
SIGNATURE __________
ADDRESSED CHECKED __
HOUSEHOLD REVISITED __
Now we would like some information about the people who usually live in your household or who are staying with you now.
001. LINE NO.
002. USUAL RESIDENTS AND VISITORS: Please give me the names of the persons who usually live in your household or are staying with you now, starting with the head of the household.
AFTER LISTING NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT YOU HAVE A COMPLETE LISTING. THEN GO ON TO 006-024.
Just to make sure that I have a complete listing:
003. Are there any other persons such as small children or infants who are not listed?
NO
004. 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
005. Do you have any guests or temporary visitors staying here, or anyone else who slept here last night?
NO
006. RELATIONSHIP TO THE HOUSEHOLD HEAD: What is (NAME)'s relationship to the head of the household?
007. RELATIONSHIP TO THE HOUSEHOLD HEAD:
FOR CODER __
008. RELATIONSHIP TO THE HOUSEHOLD HEAD:
FOR CODER __
009. RELATIONSHIP TO THE HOUSEHOLD HEAD:
FOR CODER __
010. RESIDENCE: Does (NAME) usually live here?
NO 2
011. RESIDENCE: Was (NAME) present last night?
NO 2
012. SEX: Is (NAME) male or female?
F 2
013. AGE: How old was (NAME) at his/her last birthday?
014. MARITAL STATUS, ONLY FOR PERSONS FIFTEEN YEARS AND OLDER: What is (NAME)'s current marital status?
2 WIDOWED
3 DIVORCED
4 SIGNED CONTRACT BUT NOT YET CONSUMMATED FIRST MARRIAGE
5 NEVER MARRIED
015. ELIGIBLE WOMEN: CIRCLE LINE NUMBER FOR WOMEN ELIGIBLE FOR INTERVIEW, I.E., MARRIED, WIDOWED OR DIVORCED WOMEN 15-49 YEARS OLD PRESENT IN THE HOUSEHOLD LAST NIGHT.
016. ONLY FOR THOSE THREE YEARS AND OLDER: Has (NAME) attended school in the past or is he/she currently going to school?
2 YES, CURRENTLY
3 NO, NEVER ATTENDED
017. ONLY FOR PERSONS ATTENDING SCHOOL IN PAST OR CURRENTLY: What was the highest LEVEL that he/she was admitted to?
2 PRIMARY
3 PREPARATORY
4 SECONDARY
5 UPPER INTERMEDIATE
6 UNIVERSITY
7 MORE THAN UNIVERSITY
018. ONLY FOR PERSONS ATTENDING SCHOOL IN PAST OR CURRENTLY: What was the highest GRADE that he/she successfully completed at that level?
019. ONLY FOR PERSONS NEVER ATTENDING SCHOOL OR NOT COMPLETING PRIMARY: Can (NAME) read a newspaper or a letter, for example?
NO 2
020. ONLY FOR PERSONS TWELVE YEARS AND OLDER: What is the main work that (NAME) does?
021. ONLY FOR PERSONS TWELVE YEARS AND OLDER:
OCCUPATIONAL GROUP (FOR CODER)
022. ONLY FOR PERSONS TWELVE YEARS AND OLDER WHO WORK: Did (NAME) work during the last month?
NO 2
023. Is (NAME) usually paid in cash or kind for the work he/she does?
2 KIND
3 BOTH
4 NOT PAID
024. COUNT THE NUMBER OF ELIGIBLE WOMEN FOR WHOM LINE NUMBERS ELIGIBLE NUMBERS ARE CIRCLED IN 015. ENTER THE TOTAL IN THE BOXES AT THE BOTTOM OF THE COLUMN IN 015. THEN GO TO 025.
025. CHECK THE COVER TO DETERMINE IF THE HOUSEHOLD IS INCLUDED IN THE MATERNAL MORTALITY/ANTHROPOMETRY SUBBAMPLE AND MARK THE APPROPRIATE RESPONSE BELOW. THEN FOLLOW THE SKIP INSTRUCTIONS.
NO (GO TO 034)
ASK QUESTIONS OF ALL PERSONS AGED 15 YEARS AND OLDER PRESENT IN THE HOUSEHOLD THE DAY OF THE INTERVIEW. AFTER COMPLETING THE QUESTIONS FOR ALL ELIGIBLE RESPONDENTS, GO OR TO QUESTION 034.
026. CIRCLE LINE NO. AND RECORD NAMES OF ALL PERSONS AGED 15 AND OLDER. IF PRESENT IN HOUSEHOLD, COMPLETE 027-033A AS APPROPRIATE. IF THE ELIGIBLE PERSON IS NOT PRESENT, OBTAIN INFORMATION FROM ANOTHER HOUSEHOLD MEMBER IF POSSIBLE. IF CANNOT OBTAIN INFORMATION FROM ANYONE ELSE, ENTER '97' IN 027 AND CONTINUE WITH NEXT ELIGIBLE PERSON.
027. How many sisters have you (he/she) ever had who were born to the same mother? IF NONE, ENTER '00' AND SKIP TO 033A.
028. How many of these sisters born to the same mother were married at any time? IF NONE, ENTER '00' AND SKIP TO 033A.
029. How many of these ever-married sisters are still alive? IF NONE, ENTER '00'.
030. How many of these ever-married sisters have died? IF NONE, ENTER '00' AND SKIP TO 033A.
031. How many of these ever-married sisters died while they were pregnant? IF NONE, ENTER '00'.
032. How many of these ever-married sisters died while they giving birth?
033. How many of these ever-married sisters died within six weeks after the end of a pregnancy? IF NONE, ENTER '00'.
033A. ENTER THE CODE IN THE BOX FOR THE PERSON ANSWERING QUESTIONS 027-033.
2 RESP'S BROTHER
3 RESP'S SISTER
4 OTHER RELATIVE
5 OTHER NON-RELATIVE
034. What type of dwelling unit does your household live in?
FREE STANDING HOUSE 02
OTHER (SPECIFY) ____ 03
035. Is your dwelling owned by your household or not?
OWNED JOINTLY 02
RENTED 03
OTHER (SPECIFY) ______ 04
036. MAIN MATERIAL OF THE FLOOR.
TILE (CERAMIC, CEMENT, ETC) 2
WOOD AND TILE 3
CEMENT 4
EARTH/SAND 5
OTHER (SPECIFY) ___________ 6
037. How many rooms are there in your dwelling (excluding the bathroom(s), kitchen, and stairway areas)?
038. Is there a special room used only for cooking inside or outside your dwelling?
YES, OUTSIDE DWELLING 2
NO 3
039. Is the place used for cooking shared with other households?
NO 2
040. Does the dwelling unit have electrical connections in all or only part of the dwelling unit?
YES, IN PART 2
HAS NO ELECTRICAL CONNECTIONS 3
041. What is the major source of drinking water for members of your household?
WELL WITH PUMP 02
WELL WITHOUT PUMP 03
TANKER TRUCK/OTHER VENDOR 04
NILE/CANALS 05
OTHER (SPECIFY) ___________ 06
042. Where is the major source of the water that you use for drinking located?
OUTSIDE DWELLING WITHIN SAME BUILDING 2
IN COURTYARD 3
ELSEWHERE (SPECIFY) _______ 4
043. Do you buy your drinking water from the government or from a private source?
PRIVATE SOURCE 2
OBTAIN FREE 3
044. How long does it take you to go there, get water, and come back?
ON PREMISES 966
045. Do you obtain water for household use other than drinking (e.g., handwashing, cooking, etc) from the same source?
NO 2
046. What is the major source of water for household use other than drinking?
WELL WITH PUMP 02
WELL WITHOUT PUMP 03
TANKER TRUCK/OTHER VENDOR 04
NILE/CANALS 05
OTHER (SPECIFY) ___________ 06
047. Where is the major source of the water that you use for household use other than drinking located?
OUTSIDE DWELLING WITHIN SAME BUILDING 2
IN COURTYARD 3
ELSEWHERE (SPECIFY) _________ 4
048. Does your household use water which you have stored for regular use?
NO 2
049. What kind of toilet facilities does the household have?
TRADITIONAL WITH TANK FLUSH 2
TRADITIONAL WITH BUCKET FLUSH 3
PIT 4 (GO TO 051)
BUCKET 5 (GO TO 051)
OTHER (SPECIFY) ___________ 6 (GO TO 051)
NO FACILITIES 7 (GO TO 053)
050. Is the toilet linked to a public sewer, a canal (river) or a pit?
CANAL/RIVER 2
PIT 3
051. Where are the toilet facilities located?
OUTSIDE DWELLING WITHIN SAME BUILDING 2
IN COURTYARD 3
ELSEWHERE (SPECIFY) ______ 4
052. Do you share the toilet facilities with any other household?
NO 2
053. Are any of the following items found in the dwelling unit:
NO 2
NO 2
NO 2
NO 2
054. Are any of the following appliances found in the dwelling unit:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
055. Do you or any member of your household own any of the following:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
THANK THE RESPONDENT FOR PARTICIPATING IN THE SURVEY. FILL IN THE APPROPRIATE RESPONSES IN QUESTIONS 056-057. BE SURE TO REVIEW THE QUESTIONNAIRE FOR COMPLETENESS BEFORE LEAVING THE HOUSEHOLD.
056. RECORD THE LINE NUMBER OF THE RESPONDENT FOR THE HOUSEHOLD INTERVIEW.
FAIR 2
GOOD 3
VERY GOOD 4
058. INTERVIEWER'S COMMENTS:
_________________________________
059. FIELD EDITOR'S COMMENTS:
_________________________________
060. SUPERVISOR'S COMMENTS:
_________________________________
061. OFFICE EDITOR'S COMMENTS:
________________________________