IDENTIFICATION

REGION _____________
ZONE _______________
WOREDA _____________
TOWN _______________
KEBELE _____________
ENUMERATION AREA __________
CLUSTER NUMBER _________

URBAN/RURAL:

TYPE OF PLACE:

HOUSEHOLD NUMBER ______________

NAME OF HEAD OF HOUSEHOLD _________________

HOUSEHOLD SELECTED FOR MALE INTERVIEW?

INTERVIEW VISITS

FIRST VISIT (REPEAT FOR SECOND AND THIRD VISITS)
DATE____
INTERVIEWER'S NAME____
RESULT

NEXT VISIT:
DATE___
TIME___

FINAL VISIT
DAY ______
MONTH ______
YEAR _____
INTERVIEWER NUMBER ______
RESULT ___

TOTAL NUMBER OF VISITS ___

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 _________________ ___ ___

OFFICE EDITOR ___ ___

KEYED BY ___ ___

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?

4) SEX: Is (NAME) male or female?

5) RESIDENCE: Does (NAME) usually live here?

6) Did (NAME) stay here last night?

7) AGE: How old is (NAME)?

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?

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?

13) IF ALIVE: Does (NAME)'s natural father live in this household?
IF YES: What is his name?
RECORD FATHER'S LINE NUMBER.

IF AGE 5 YEARS OR OLDER:

14) LITERACY: Is (NAME) able to read and write a simple sentence?

15) EDUCATION: Has (NAME) ever had any formal education?

16) What is the highest grade (NAME) completed?

CURRENT SCHOOL ATTENDANCE IF AGE 5-24 YEARS

17) Is (NAME) currently attending school?

18) During the current school year, did (NAME) attend school at any time?

19) During the current school year, what grade [is/was] (NAME) attending?

20) During the previous school year, did (NAME) attend school at any time?

20A) During that school year, what grade did (NAME) attend?

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?

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?

3) Are there any guests or temporary visitors staying here, or anyone else who slept here last night, who have not been listed?

21. What is the main source of drinking water for members of your household?

22. How long does it take you to go there, get water and come back?

23. What kind of toilet facility do most members of your household use?

24. Do you share this facility with other households?

25. Does your household have:

25A. Does your household:

26. What type of fuel does your household mainly use for cooking?

27. MAIN MATERIAL OF THE FLOOR.
RECORD OBSERVATION.

27A. MAIN MATERIAL OF THE ROOF.
RECORD OBSERVATION.

27B. How many rooms in your house are used for sleeping?

28. Does any member of your household own:

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:

29A. CHECK 29:

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.

29C. Has any member of your household bought any drugs during the last 12 months?

29D.Where were the drugs mainly bought?

29F. Does your household have any bednets that can be used while sleeping?

29G. Was the bednent ever treated with a product to kill mosquitoes?

35. ASK RESPONDENT FOR A TEASPOONFUL OF SALT. TEST SALT FOR IODINE.
RECORD PPM (PARTS PER MILLION).

HEIGHT AND WEIGHT MEASUREMENT

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)

37) NAME FROM COL. (2)

38) AGE FROM COL. (7)

39) What is (NAME)'s date of birth?
[ONLY FOR CHILDREN UNDER AGE 6]

40) WEIGHT (KILOGRAMS)

41) HEIGHT (CENTIMETERS)

42) MEASURED LYING DOWN OR STANDING UP
[ONLY FOR CHILDREN UNDER AGE 6]

43) RESULT