REGION _____________
ZONE _______________
WOREDA _____________
TOWN _______________
KEBELE _____________
ENUMERATION AREA __________
CLUSTER NUMBER _________
RURAL 2
SMALL CITY 2
TOWN 3
COUNTRYSIDE 4
HOUSEHOLD NUMBER ______________
NAME OF HEAD OF HOUSEHOLD _________________
HOUSEHOLD SELECTED FOR MALE INTERVIEW?
NO 2
INTERVIEW VISITS
FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S 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
FINAL VISIT
DAY ______
MONTH ______
YEAR _____
INTERVIEWER NUMBER ______
RESULT ___
TOTAL PERSONS IN HOUSEHOLD ___ ___
TOTAL ELIGIBLE WOMEN ___ ___
TOTAL ELIGIBLE MEN ___ ___
TOTAL ELIGIBLE CHILDREN ___ ___
LINE NUMBER OF RESPONDENT TO HOUSEHOLD QUESTIONNAIRE ___ ___
SUPERVISOR
NAME _________________
DATE _________________ ___ ___
FIELD EDITOR
NAME _________________
DATE _________________ ___ ___
HOUSEHOLD SCHEDULE
Now we would like some information about the people who usually live in your household or who are staying with you now.
1) LINE NO.
2) 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.
3) RELATIONSHIP TO HEAD OF HOUSEHOLD: What is the relationship of (NAME) to the head of the household?
WIFE OR HUSBAND OR PARTNER 02
SON OR DAUGHTER 03
SON-IN-LAW OR DAUGHTER-IN-LAW 04
GRANDCHILD 05
PARENT 06
PARENT-IN-LAW 07
BROTHER OR SISTER 08
ADOPTED/FOSTER/STEPCHILD 10
OTHER RELATIVE 11
NOT RELATED 12
DON'T KNOW 98
4) SEX: Is (NAME) male or female?
FEMALE 2
5) RESIDENCE: Does (NAME) usually live here?
NO 2
6) Did (NAME) stay here last night?
NO 2
ELIGIBILITY:
8) CIRCLE LINE NUMBER OF ALL WOMEN AGE 15-49
9) CIRCLE LINE NUMBER OF ALL CHILDREN UNDER AGE 6
9A) CIRCLE LINE NUMBER OF ALL MEN AGE 15-59
PARENTAL SURVIVORSHIP AND RESIDENCE FOR PERSONS LESS THAN 15 YEARS OF AGE
Q.10 THROUGH Q.13:
THESE QUESTIONS REFER TO THE BIOLOGICAL PARENTS OF THE CHILD.
IN Q.11 AND Q.13, RECORD '00' IF PARENT NOT LISTED IN HOUSEHOLD SCHEDULE.
10) Is (NAME)'s natural mother alive?
NO 2
DON'T KNOW 8
11) IF ALIVE: Does (NAME)'s natural mother live in this household?
IF YES: What is her name?
RECORD MOTHER'S LINE NUMBER
12) Is (NAME)'s natural father alive?
NO 2
DON'T KNOW 8
13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.
14) LITERACY: Is (NAME) able to read and write a simple sentence?
NO 2
DON'T KNOW 8
15) EDUCATION: Has (NAME) ever had any formal education?
NO 2 (GO TO NEXT LINE)
16) What is the highest grade (NAME) completed?
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE 15
DON'T KNOW 98
CURRENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS
17) Is (NAME) currently attending school?
NO 2
18) During the current school year, did (NAME) attend school at any time?
NO 2 (GO TO 20)
19) During the current school year, what grade [is/was] (NAME) attending?
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE 15
DON'T KNOW 98
20) During the previous school year, did (NAME) attend school at any time?
NO 2 (GO TO NEXT LINE)
20A) During that school year, what grade did (NAME) attend?
GRADE COMPLETED 01-12
TECHNICAL/VOCATIONAL CERTIFICATE 13
UNIVERSITY/COLLEGE DIPLOMA 14
UNIVERSITY/COLLEGE DEGREE 15
DON'T KNOW 98
TICK HERE IF CONTINUATION SHEET USED___
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 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
21. What is the main source of drinking water for members of your household?
PIPED INTO COMPOUND 12 (GO TO 23)
PIPED OUTSIDE COMPOUND 13
OPEN SPRING 23
COVERED SPRING 32
POND/LAKE/DAM 43
OTHER (SPECIFY)___________ 96
22. How long does it take you to go there, get water and come back?
ONE DAY OR LONGER 995
ON PREMISES 996
23. What kind of toilet facility do most members of your household use?
VENTILATED IMPROVED PIT LATRINE (VIP) 22
OTHER (SPECIFY)____________ 96
24. Do you share this facility with other households?
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
26. What type of fuel does your household mainly use for cooking?
LPG/NATURAL GAS 02
BIOGAS 03
KEROSENE 04
CHARCOAL 05
FIREWOOD, STRAW 06
DUNG 07
OTHER (SPECIFY)__________________ 96
27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.
DUNG 12
WOOD PLANKS 21
REED/BAMBOO 22
PARQUET OR POLISHED WOOD 31
VINYL SHEETS/TILES 32
CEMENT 33
CEMENT TILES/BRICK 34
CARPET 35
OTHER (SPECIFY)___________ 96
27A. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.
CEMENT/CONCRETE 02
WOOD AND MUD 03
THATCH 04
REED/BAMBOO 05
PLASTIC SHEET 06
MOBILE ROOFS OF NOMADS 07
OTHER (SPECIFY)__________ 96
27B. How many rooms in your house are used for sleeping?
28. Does any member of your household own:
NO 2
NO 2
NO 2
NO 2
29. Has any member of your household received any of the following services at a health facility at any time in the past 12 months:
NO 2
NO 2
NO 2
NO 2
NO 2
NO 2
NOT A SINGLE "YES" (GO TO 29C)
29B. From what facilities have members received these services?
PROBE: Anywhere else?
RECORD BELOW TYPE AND/OR LOCATION OF ALL FACILITIES VISITED BY HOUSEHOLD MEMBERS IN PAST 12 MONTHS. THEN CIRCLE CODE FOR EACH TYPE OF FACILITY MENTIONED.
HEALTH CENTER B
HEALTH STATION/CLINIC C
HEALTH POST D
COMMUNITY-BASED OUTLET E
OTHER GOVERNMENT (SPECIFY)___________F
COMMUNITY-BASED OUTLET H
OTHER NGO (SPECIFY) _____________ I
PRIVATE DOCTOR/CLINIC K
OTHER PRIVATE (SPECIFY)_____________ L
29C. Has any member of your household bought any drugs during the last 12 months?
NO 2 (GO TO 29F)
29D.Where were the drugs mainly bought?
NON MEDICAL FACILITY B
29F. Does your household have any bednets that can be used while sleeping?
NO 2 (GO TO 35)
29G. Was the bednent ever treated with a product to kill mosquitoes?
NO 2
35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).
7 PPM 2
15 PPM 3
30 PPM 4
CHECK COLUMN (8): RECORD THE LINE NUMBER, NAME AND AGE OF ALL WOMEN AGE 15-49 IN Q.36 TO Q.38 IN THE HEIGHT AND WEIGHT GRID FOR WOMEN BELOW. THEN CHECK COLUMN (9) AND RECORD THE LINE NUMBER,
NAME AND AGE OF ALL CHILDREN UNDER AGE 6 IN COLUMNS Q.44-Q.46 IN THE HEIGHT AND WEIGHT GRID FOR CHILDREN.
36) LINE NO. FROM COL (8)/(9)
39) What is (NAME)'s date of birth?
[ONLY FOR CHILDREN UNDER AGE 6]
MONTH___
YEAR___
42) MEASURED LYING DOWN OR STANDING UP
[ONLY FOR CHILDREN UNDER AGE 6]
STANDING 2
NOT PRESENT 2
REFUSED 3
OTHER 4