IDENTIFICATION
GOVERNORATE __________
KISM/MARKAZ __________
SHIAKHA/VILLAGE __________
HOUSEHOLD NO. ___________
PSU/SEGMENT NO. ________
BUILDING NO._________
HOUSE NO. ______________
URBAN 1
RURAL 2
LARGE CITY 1
SMALL CITY 2
TOWN 3
VILLAGE 4
SUBSAMPLE:
YES 1
NO 2
NAME OF HOUSEHOLD HEAD _______
ADDRESS IN DETAIL _____
GOVERNORATE __
PSU/SEGMENT NO. ___
HOUSEHOLD NO. ____
URBAN/RURAL ____
LOCALITY ___
SUBSAMPLE ___
INTERVIEWER VISITS 1
DATE _____
TEAM _____
INTERVIWER'S NAME _____
SUPERVISOR'S NAME _____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 2
DATE _____
TEAM _____
INTERVIEWER'S NAME _____
SUPERVISOR'S NAME _____
RESULT ______
NEXT VISIT: DATE _____ TIME ________
INTERVIEWER VISITS 3
DATE _____
TEAM _____
INTERVIWER'S NAME_____
SUPERVISOR'S NAME _____
RESULT ______
FINAL VISIT
DAY ____ MONTH ____ YEAR ____
TEAM ____
INTERVIEWER _____
SUPERVISOR _____
RESULT _____
TOTAL VISITS ____
2 NO HOUSEHOLD MEMBER AT HOME OR NO COMPETENT PERSON AT HOME AT THE TIME OF VISIT
3 ENTIRE HOUSEHOLD ABSENT FOR AN EXTENDED PERIOD
4 POSTPONED
5 REFUSED
6 DWELLING VACANT OR ADDRESS NOT A DWELLING
7 DWELLING DESTROYED
8 DWELLING NOT FOUND
9 OTHER (SPECIFY) _______
TOTAL IN HOUSEHOLD __
TOTAL ELIGIBLE WOMEN __
TOTAL ELIGIBLE MEN__
LINE NO. OF RESPONDENT FOR HOUSEHOLD SCHEDULE __
ADDRESS CHECKED (by NAME): ________
NO 2
NO 2
FIELD EDITOR
NAME _______
DATE _______
SIGNATURE _______
OFFICE EDITOR
NAME _______
DATE _______
SIGNATURE _______
CODER
NAME _______
DATE _______
SIGNATURE _______
KEYER
NAME _______
DATE _______
SIGNATURE _______
We would like some information about 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 and guests of the household who stayed here last night, starting with the head of the household.
AFTER LISTING NAMES, ASK QUESTIONS 003-005 TO BE SURE THAT THE LISTING IS COMPLETE. THEN GO ON TO QUESTION 006.
Just to make sure that I have a complete listing.
003. Are there any other persons such as small children or infants that we have 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 the relationship of (NAME) to the head of the household?
007. RELATIONSHIP TO THE HOUSEHOLD HEAD: GENERATION NUMBER
008. RELATIONSHIP TO THE HOUSEHOLD HEAD: COUPLE NUMBER
009. RELATIONSHIP TO THE HOUSEHOLD HEAD: RELATIONSHIP TO HEAD OF HOUSEHOLD
010. RESIDENCE: Does (NAME) usually live here?
NO 2
011. RESIDENCE: Did (NAME) sleep here 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, IF AGE 15 YEARS OR OLDER: What is (NAME'S) current marital status?
2 WIDOWED
3 DIVORCED
4 NEVER MARRIED/ SIGNED CONTRACT
015. ELIGIBLITY: CIRCLE LINE NUMBER OF WOMEN ELIGIBLE FOR INDIVIDUAL INTERVIEW (i.e., EVER-MARRIED WOMEN AGE 15-49 YEARS WHO ARE USUAL RESIDENTS OR STAYED THERE ON THE NIGHT BEFORE INTERVIEW).
016. ELIGIBLITY: HUSBAND SUBSAMPLE: FOR HOUSEHOLDS IN HUSBAND SURVEY SUBSAMPLE: CIRCLE LINE NUMBER OF MEN ELIGIBLE FOR INDIVIDUAL INTERVIEW (I.E., MEN WHOSE WIVES ARE ELIGIBLE)
017. EDUCATION: IF AGE 3 YEARS OR OLDER: Has (NAME) ever been to school? IF YES, ASK QUESTIONS 018-020. IF NO, SKIP TO QUESTION 021.
NO 2
018. EDUCATION: IF AGE 3 YEARS OR OLDER: IF ATTENDED SCHOOL: What is the highest level of school (NAME) attended?
PRIMARY 1
PREPARATORY 2
SECONDARY 3
UPPER INTERMEDIATE 4
UNIVERSITY 5
MORE THAN UNIVERSITY 6
019. EDUCATION: IF AGE 3 YEARS OR OLDER: IF ATTENDED SCHOOL: What is the highest grade he/she successfully completed at that level?
020. EDUCATION: IF AGE 3 YEARS OR OLDER: IF ATTENDED SCHOOL: FOR PERSONS UNDER AGE 25: Is (NAME) still in school?
NO 2
021. OCCUPATION: IF AGE 6 YEARS OR OLDER: What is main work that (NAME) does?
022. OCCUPATION: IF AGE 6 YEARS OR OLDER: OCCUPATIONAL GROUP
023. WORK STATUS: IF AGE 6 YEARS OR OLDER: Did (NAME) work during the last month?
NO 2
024. WORK STATUS: IF AGE 6 YEARS OR OLDER: Is (NAME) usually paid in cash or kind for the work he/she does?
KIND 2
BOTH 3
NOT PAID 4
025. ENTER THE TOTAL NUMBER OF ELIGIBLE:
MEN___
026. TICK HERE IF CONTINUATION SHEET USED: ___
027. What type of dwelling does your household live in?
FREE STANDING HOUSE 2
OTHER (SPECIFY) ____ 3
028. Is your dwelling owned by your household or not? IF OWNED: Is it owned solely by your household or jointly with someone else?
OWNED JOINTLY 2
RENTED 3
OTHER (SPECIFY) ______ 4
029. MAIN MATERIAL OF THE FLOOR. RECORD YOUR OBSERVATIONS.
CERAMIC/MARBLE TILES 32
CEMENT TILES 33
CEMENT 34
WALL-TO-WALL CARPET 35
030. How many rooms are there in your dwelling (excluding the bathrooms, kitchens and stairway areas)?
031. How many of the rooms are used for sleeping?
032. Is there a special room used only for cooking inside or outside the dwelling?
NO 2
033. What is the source of water your household uses for drinking?
PUBLIC TAP 12
PUBLIC WELL 22
034. How long does it take to go there, get water, and come back?
035. Does your household get water for other uses (e.g., for handwashing and dishwashing) from the same source?
NO 2
036. What is the source of water your household uses for handwashing or dishwashing or other uses?
PUBLIC TAP 12
PUBLIC WELL 22
037. What kind of toilet facility does your household have?
TRADITIONAL WITH TANK FLUSH 12
TRADITIONAL WITH BUCKET FLUSH 13
PIT TOILET/LATRINE 21
NO FACILITY 31
OTHER (SPECIFY) ______ 41
038. Are there electrical connections in all or only part of the dwelling unit?
YES, IN PART 2
HAS NO ELECTRICAL CONNECTIONS 3
039. Does your household have:
NO 2
NO 2
NO 2
NO 2
040. Does your household have:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
041. Do you or any member of your household own:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
THANK THE RESPONDENT FOR PARTICIPATING IN THE SURVEY. COMPLETE QUESTIONS 042-043 AS APPROPRIATE. BE SURE TO REVIEW THE QUESTIONNAIRE FOR COMPLETENESS BEFORE LEAVING THE HOUSEHOLD.
FAIR 2
GOOD 3
VERY GOOD 4
043. INTERVIEWER'S COMMENTS:
_________________________________
044. FIELD EDITOR'S COMMENTS:
_________________________________
045. SUPERVISOR'S COMMENTS:
_________________________________
046. OFFICE EDITOR'S COMMENTS:
_________________________________